Health Net
Plegridy Starter Pack (peginterferon beta-1a)
Drugs for the Nervous System : Drugs for Multiple Sclerosis
  • 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: >= 6 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