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 BETASERON KIT Y    
interferon beta-1b EXTAVIA KIT Y    
alemtuzumab LEMTRADA VIAL N    
daclizumab ZINBRYTA SYRINGE N PA Document Jan 26, 2017
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 GLATIRAMER ACETATE SYRINGE N    
glatiramer acetate GLATOPA SYRINGE 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