CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Betaseron Extavia 1840 A Sgm P2024

Defines coverage and authorization criteria for Betaseron and Extavia for treatment of relapsing forms of multiple sclerosis (including clinically isolated syndrome and active secondary progressive disease) when prescribed by or in consultation with a neurologist. Specifies authorization duration and restrictions on concomitant use with other disease-modifying MS agents.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBetaseron Extavia 1840 A Sgm P2024

Policy CodePolicy N/A

Change TypeClarified indications

Effective Date

Next Review Date

Key ActionObtain authorization for 12 months and ensure the medication is prescribed by or in consultation with a neurologist.

SourceLink

POLICY UPDATE CHANGES

Indications limited to FDA-approved and compendial uses; all other indications considered experimental/investigational and not medically necessary.

12Authorization Duration (months)

3Covered Indication Categories

Coverage Summary

Defines coverage and authorization criteria for Betaseron and Extavia for treatment of relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease) in adults. Medication must be prescribed by or in consultation with a neurologist. Authorization of 12 months may be granted for initial therapy and for continuation when criteria are met. Use concomitantly with other disease‑modifying multiple sclerosis agents is not allowed; indications outside the FDA‑approved/compendial uses are considered experimental/investigational and not medically necessary.

Initial Therapy Criteria

Covered Indications / Initial Authorization

Authorization of 12 months may be granted when ALL of the following are met:

Diagnosis of a relapsing form of multiple sclerosis (including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease) in adults
Consistent with FDA-approved indications
Prescriber: Medication prescribed by or in consultation with a neurologist
Prescriber specialty requirement
Benefit exclusions: Member has no exclusions to the prescribed therapy
Membership/benefit exclusions must be checked

Continuation Therapy Criteria

Continuation of Therapy

Authorization of 12 months may be granted when ALL of the following are met:

Continuation of Therapy: Member is experiencing disease stability or improvement while receiving Betaseron or Extavia

Clinical assessment required to support continued benefit

Documentation Required

Clinical documentation for continuation

Provider must document disease stability or improvement to support continuation authorization.

Provider Actions / Prior Authorization

Prior Authorization

Authorization required

Authorization of 12 months may be granted for initial and continuation therapy when criteria are met; prescriber must be a neurologist or consult with one.

Documentation Required

Clinical documentation for continuation

Provider must document disease stability or improvement to support continuation authorization.

Background & Definitions

Betaseron and Extavia are interferon beta‑1b formulations indicated for treatment of relapsing forms of multiple sclerosis in adults. The policy follows FDA labeling, requires that the medication be prescribed by or in consultation with a neurologist, and requires documentation of disease stability or improvement to support continuation of therapy.

Term	Definition
Clinically isolated syndrome (CIS)	A single episode of neurologic symptoms that may represent the first manifestation of multiple sclerosis.
Relapsing forms of multiple sclerosis	Includes clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease.