CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Betaseron and Extavia (interferon beta-1b) — Coverage Criteria

Covers use of Betaseron and Extavia for FDA‑approved relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting, and active secondary progressive disease) when approval criteria are met; applies to members of Neighborhood Health Plan of Rhode Island under the payer's pharmacy/medical benefit as specified. Prescribing must be by or in consultation with a neurologist.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBetaseron and Extavia (interferon beta-1b) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for up to 12 months and ensure prescribing is by or in consultation with a neurologist.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization period

neurologistprescriber requirement

FDA‑approved onlycoverage stance

Coverage Criteria for Betaseron and Extavia

Coverage criteria for Betaseron and Extavia

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FDA‑approved indication: Member has a diagnosis of a relapsing form of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting disease, or active secondary progressive disease)

FDA‑approved indications only; all other indications are considered experimental/investigational and not medically necessary

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

Authorization period: Request is for up to 12 months for initial therapy or continuation of therapy12 months

Continuation requires disease stability or improvement while receiving Betaseron or Extavia

Provider Requirements, Authorization, and Documentation

Prior Authorization

Authorization period — initial and continuation

Prior authorization may be granted for up to 12 months for members with relapsing forms of multiple sclerosis or for clinically isolated syndrome. Continuation approvals of 12 months may be granted when the member demonstrates disease stability or improvement while receiving Betaseron or Extavia.

Step Therapy

No concomitant DMTs

Members must not use Betaseron or Extavia at the same time as other disease‑modifying multiple sclerosis agents.

Documentation Required

Required clinical documentation and prescriber specialty

Document the diagnosis consistent with a relapsing form of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting, or active secondary progressive disease) and that the medication is prescribed by or in consultation with a neurologist.

Denial Risk

Non‑FDA indications are not covered

Use of Betaseron or Extavia for indications other than the FDA‑approved relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting, and active secondary progressive disease) is considered experimental/investigational and not medically necessary and may be denied.

Key Definitions

Relapsing forms of multiple sclerosis — definition and coverage scope

DefinitionRelapsing forms of multiple sclerosis include clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease as stated in the FDA‑approved indication.

ScopeApplies to adults as specified in the FDA‑approved indication.

Coverage stanceOnly FDA‑approved relapsing forms of MS are considered eligible; all other indications are experimental/investigational and not medically necessary.

Background on Betaseron and Extavia

Betaseron and Extavia (interferon beta‑1b) are indicated for the treatment of relapsing forms of multiple sclerosis, which include clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease in adults. This policy restricts coverage to those FDA‑approved relapsing forms; other uses are considered investigational.