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
Status
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    
DACLIZUMAB ZINBRYTA SYRINGE N PA Document Jan 26, 2017
DALFAMPRIDINE AMPYRA TAB ER 12H N PA Document Jul 25, 2013
DIMETHYL FUMARATE TECFIDERA CAPSULE DR N PA Document  
FINGOLIMOD HCL GILENYA CAPSULE N PA Document Mar 29, 2012
GLATIRAMER ACETATE GLATOPA SYRINGE N    
INTERFERON BETA-1B EXTAVIA VIAL N    
OCRELIZUMAB OCREVUS VIAL N    
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