- Quantity Limits Apply
- Prior Authorization: Multiple Sclerosis (MS):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 10
Duration: 1 plan year
Reauthorization Required: Yes
- I. Health Net Approved Indications and Usage Guidelines: A. Approved for relapsing remitting multiple sclerosis (RRMS) confirmed by a neurologist. II. Coverage is Not Authorized For: Primary progressive multiple sclerosis. III. Authorization Limit: Length of Benefit; For AHCS requests: One Year.
- Multiple Sclerosis (MS):
Age Requirement: >= 10
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
Supporting Documentation Requirements: 3 of Chart Notes;Documentation of baseline number of relapses per year;Documentation of expanded disability status scale (EDSS) score;Lab Tests
- Limited Access. Must use AcariaHealth Specialty Rx.
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