CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Betaseron (interferon beta-1b) / Extavia coverage for relapsing forms of multiple sclerosis

Defines coverage criteria for Betaseron and Extavia (interferon beta-1b) for FDA-approved and compendial uses in relapsing forms of multiple sclerosis, including clinically isolated syndrome; specifies prescriber specialty, duration of authorization, continuation criteria, and concomitant therapy exclusions.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBetaseron (interferon beta-1b) / Extavia coverage for relapsing forms of multiple sclerosis

Policy CodePolicy N/A

Change TypeClarified

Effective DateN/A

Next Review DateN/A

Key ActionAuthorization is required and may be granted for up to 12 months for initial and continuation therapy when criteria are met; prescriber must be a neurologist or consult with a neurologist.

POLICY UPDATE CHANGES

No material clinical or coverage changes identified; policy clarifies FDA-approved indications and notes other uses are investigational/not medically necessary.

3Covered Indication Categories (relapsing forms, clinically isolated syndrome, continuation)

12Authorization Duration (months)

1Required Prescriber Specialty (neurology)

Coverage Summary & Scope

Scope: Coverage is defined for Betaseron and Extavia (interferon beta-1b) for FDA-approved treatment of relapsing forms of multiple sclerosis in adults, including clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease. Other uses are considered experimental/investigational and not medically necessary. The policy references package inserts (November 2021) as supporting evidence for the FDA‑approved indications.

Key Coverage Facts

Covered Indication Categories3 (relapsing forms of MS including clinically isolated syndrome, relapsing‑remitting, active secondary progressive; continuation)

Authorization Duration12 months (initial and renewal/continuation)

Required Prescriber SpecialtyMust be prescribed by or in consultation with a neurologist

Continuation CriteriaDisease stability or improvement while receiving Betaseron or Extavia required for continuation approvals

Concomitant Therapy ExclusionNot covered if used concomitantly with other disease‑modifying MS agents

Last Review2022-03 (references/package insert Nov 2021)

Initial Therapy Criteria

FDA-Approved Indications / Initial Authorization

Covered when ALL of the following are met:

ALL of the following

Diagnosis of a relapsing form of multiple sclerosis (includes clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease) in an adult
Prescriber specialty requirement: Medication prescribed by or in consultation with a neurologist
Prescriber specialty requirement
Exclusion screening: Member has no exclusions to the prescribed therapy
Implied benefit/exclusion screening

Clinically Isolated Syndrome

Covered when ALL of the following are met:

ALL of the following

Diagnosis of clinically isolated syndrome of multiple sclerosis
Prescriber specialty requirement: Medication prescribed by or in consultation with a neurologist
Prescriber specialty requirement

Authorization Duration

Authorization rules:

ANY of the following

Relapsing form duration: Initial or renewal authorization may be granted for up to 12 months for members with a relapsing form of MS12 months
CIS duration: Authorization of 12 months may be granted for members with clinically isolated syndrome12 months

Continuation Therapy Criteria

Continuation of Therapy

Covered continuation when ALL of the following are met:

ALL of the following

Disease response: Member is experiencing disease stability or improvement while receiving Betaseron or Extavia
Prescriber specialty requirement: Prescriber maintains specialty requirement (neurologist or consult)
Prescriber specialty requirement

Exclusions / Not Medically Necessary

Concomitant Therapy Exclusion

Not covered when the following is present:

Concomitant therapy exclusion: Betaseron or Extavia used concomitantly with other disease-modifying multiple sclerosis agents is not covered

Concomitant use with other DMTs is not allowed

Background: Uses of Betaseron or Extavia beyond the FDA‑approved relapsing MS indications are considered experimental/investigational and not medically necessary per this policy. Concomitant use with other disease‑modifying multiple sclerosis agents is not allowed and may result in claim denial.

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

Authorization is required and may be granted for up to 12 months for initial and continuation therapy when criteria are met; prescriber must be a neurologist or consult with a neurologist. No specific codes provided.

Documentation Required

Documentation of Diagnosis and Response

Provider must document diagnosis (relapsing form of MS or clinically isolated syndrome), prescriber specialty (neurologist or consultation), and evidence of disease stability or improvement for continuation approvals.

Diagnosis of a relapsing form of multiple sclerosis (includes clinically isolated syndrome, relapsing‑remitting, active secondary progressive)
Medication prescribed by or in consultation with a neurologist
Evidence of disease stability or improvement for continuation of therapy

Denial Risk

Denied if Concomitant DMTs

Claims may be denied if Betaseron or Extavia are used concomitantly with other disease-modifying multiple sclerosis agents.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBetaseron (interferon beta-1b) / Extavia coverage for relapsing forms of multiple sclerosis

Policy CodePolicy N/A

Change TypeClarified

Effective DateN/A

Next Review DateN/A

Key ActionAuthorization is required and may be granted for up to 12 months for initial and continuation therapy when criteria are met; prescriber must be a neurologist or consult with a neurologist.

On This Page

OpenPayer

Betaseron (interferon beta-1b) / Extavia coverage for relapsing forms of multiple sclerosis

Coverage Summary & Scope

Initial Therapy Criteria

Continuation Therapy Criteria

Exclusions / Not Medically Necessary

Applicable Codes

Provider Actions & Authorization

Clinical Evidence & References

Definitions

Revision History