| Health Net |
| Mavenclad (7 Tabs) (cladribine(multiple sclerosis)) |
| Drugs for the Nervous System : Drugs for Multiple Sclerosis |
- Step Therapy Applies
- Quantity Limit: limit maximum 7 EA PER 30 day(s)
- Multiple Sclerosis (MS):
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
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
Secondary Progressive Multiple Sclerosis:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
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