- Step Therapy Applies
- Must use AcariaHlth Sp Rx
- Prior Authorization: Multiple Sclerosis (MS):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Multiple Sclerosis (MS):
Age Requirement: >= 18
Duration: 6 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;Lab Tests
- 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.
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