CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Teriflunomide (Aubagio) for relapsing multiple sclerosis — Coverage Criteria

Covers use of teriflunomide (Aubagio) for FDA-approved relapsing forms of multiple sclerosis and certain compendial uses when approval criteria are met; applies to prescribers and members under Neighborhood Health Plan of Rhode Island benefits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTeriflunomide (Aubagio) for relapsing multiple sclerosis — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis of a relapsing form of multiple sclerosis; authorization may be granted for up to 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 motypical authorization duration

Neurologistrequired prescriber specialty

Permittedpediatric use

Relapsing MSFDA-approved indication covered

Coverage Criteria for Teriflunomide (Aubagio)

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Initial and Continuation Coverage Criteria

Covered when ALL of the following are met:

FDA indication: Patient has a relapsing form of multiple sclerosis (clinically isolated syndrome, relapsing‑remitting MS, or active secondary progressive MS)

FDA‑approved indication required

Prescriber: Medication is prescribed by or in consultation with a neurologist

Neurologist involvement required

Authorization period: Initial and continuation authorizations requested for up to 12 months12 months

Continuation requires disease stability or improvement

All indications outside the FDA‑approved relapsing forms of multiple sclerosis are considered experimental/investigational and not medically necessary. The FDA‑approved indication covers treatment of adults with relapsing forms of MS, including clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease; requests for other diagnoses should be denied as not covered.

Concomitant therapy with other disease‑modifying multiple sclerosis agents is not allowed. Members must not use the requested medication together with other disease‑modifying MS treatments (note that non‑DMT agents such as Ampyra and Nuedexta are not classified as disease‑modifying and are not included in this restriction).

Use of this medication for indications other than the FDA‑approved relapsing forms of multiple sclerosis is not medically necessary and is considered experimental/investigational; such uses are excluded from coverage.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Length and Continuation

Authorization of 12 months may be granted for members diagnosed with a relapsing form of multiple sclerosis (including relapsing‑remitting MS and active secondary progressive MS) and for members with clinically isolated syndrome. For continuation of therapy, 12‑month authorizations may be granted when the member is stable or demonstrating improvement while receiving the requested medication.

Authorization length: 12 months for initial therapy and continuation when member is stable or improving.
Required diagnosis: relapsing form of MS (clinically isolated syndrome, relapsing‑remitting MS, active secondary progressive MS).

Documentation Required

Required Diagnostic Documentation

Requests must include documentation confirming the diagnosis and clinical details supporting the relapsing MS indication.

Diagnosis documentation showing relapsing form of MS: Clinically isolated syndrome (CIS), relapsing‑remitting MS (RRMS), or active secondary progressive MS (SPMS).
Clinical evidence supporting the diagnosis and need for therapy (e.g., clinical notes, MRI reports, relapse history, EDSS or functional assessments).

Documentation Required

Concomitant Disease‑Modifying Therapy Restriction

Members must not use the requested medication concomitantly with other disease‑modifying therapies for multiple sclerosis.

Concomitant use with other DMTs is prohibited (note: Ampyra and Nuedexta are not disease‑modifying therapies).

Denial Risk

Non‑Approved Indication Denial Risk

Requests for indications other than the FDA‑approved relapsing forms of MS (including non‑compendial uses) are considered experimental/investigational and may be denied.

Non‑FDA relapsing indications and non‑compendial uses are not medically necessary and are subject to denial.

Definitions

Relapsing forms of multiple sclerosis — definition and coverage note

DefinitionRelapsing forms of multiple sclerosis include clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease (per FDA indication).

Age groupIndication applies to adults.

Coverage scopeCovered when the diagnosis matches the FDA‑approved relapsing forms of MS.

Non‑covered usesAll other indications are considered experimental/investigational and not medically necessary.