Multiple Sclerosis

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Drug Use Review Documents

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Current Drug Use Criteria New Drug Evaluation
glatiramer acetate COPAXONE SYRINGE Y 40 mg/mL Require PA  
interferon beta-1a AVONEX PEN PEN IJ KIT Y    
interferon beta-1a AVONEX SYRINGEKIT Y    
interferon beta-1a/albumin AVONEX KIT Y    
interferon beta-1a/albumin REBIF REBIDOSE PEN INJCTR Y    
interferon beta-1a/albumin REBIF SYRINGE Y    
interferon beta-1b EXTAVIA KIT Y    
interferon beta-1b BETASERON KIT Y    
alemtuzumab LEMTRADA VIAL N    
dalfampridine DALFAMPRIDINE ER TAB ER 12H N PA Document  
dalfampridine AMPYRA TAB ER 12H N PA Document Mar 29, 2012
dimethyl fumarate TECFIDERA CAPSULE DR N PA Document  
fingolimod HCl GILENYA CAPSULE N PA Document Mar 29, 2012
glatiramer acetate GLATOPA SYRINGE N    
glatiramer acetate GLATIRAMER ACETATE SYRINGE N    
interferon beta-1b BETASERON VIAL N    
interferon beta-1b EXTAVIA VIAL N    
ocrelizumab OCREVUS VIAL N PA Document  
peginterferon beta-1a PLEGRIDY PEN PEN INJCTR N PA Document  
peginterferon beta-1a PLEGRIDY SYRINGE N PA Document  
teriflunomide AUBAGIO TABLET N PA Document May 30, 2013
amifampridine phosphate FIRDAPSE TABLET PA Document  
cladribine MAVENCLAD TABLET PA Document  
fingolimod HCl GILENYA CAPSULE PA Document Mar 29, 2012
siponimod MAYZENT TAB DS PK PA Document  
siponimod MAYZENT TABLET PA Document