CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Teriflunomide (Aubagio) — Coverage Criteria

Covers use of teriflunomide (Aubagio) for FDA‑approved relapsing forms of multiple sclerosis and 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) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for up to 12 months when the medication is prescribed by or in consultation with a neurologist and criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

neurologistprescriber restriction

FDA-approved onlycoverage scope

case-by-casepediatric exception

Coverage Criteria

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

Primarily adults; authorization for pediatric members (<18 years) may be granted when benefits outweigh risks.

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

Concomitant therapy: Member is not using teriflunomide concomitantly with other disease‑modifying multiple sclerosis agents.

Ampyra and Nuedexta are not disease‑modifying agents.

Authorization period: Request is for an authorization period up to 12 months (initial or continuation).12 months

Continuation requires disease stability or improvement.

Coding and Authorization Duration

No codes specified in sourcemixed

No codes listed

Authorization duration

Typical authorization durationAuthorization may be granted for up to 12 months for initial and continuation therapy.

Continuation requirementContinuation authorizations (12 months) require the member to be experiencing disease stability or improvement while on therapy.

Clinically isolated syndromeAuthorization of 12 months may be granted specifically for treatment of clinically isolated syndrome.

Relapsing and secondary progressive diseaseAuthorization of 12 months may be granted for members diagnosed with relapsing forms of MS, including relapsing‑remitting and secondary progressive disease with ongoing relapses.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Duration

Authorization duration — prior authorization may be granted for 12 months for eligible members for initial and continuation therapy when criteria are met.

Denial Risk

No Concomitant Disease‑Modifying Therapy (DMT)

Concomitant DMT restriction — members must not use teriflunomide concomitantly with other disease-modifying multiple sclerosis agents. Verify that no concurrent DMT is documented in the medical record. (Note: Ampyra and Nuedexta are not disease-modifying therapies.)

Documentation Required

Prescriber Requirements and Documentation

Prescriber and Concomitant Therapy — medication must be prescribed by or in consultation with a neurologist. Include documentation of neurologist involvement with the prescription and provide rationale if any concomitant therapy is being considered or has been used.

Denial Risk

Coverage for Non‑FDA Indications

Non‑FDA Indications — requests for indications other than FDA‑approved relapsing forms of MS (to include clinically isolated syndrome, relapsing‑remitting, and active secondary progressive disease) are considered experimental/investigational and are not medically necessary unless adequate justification is provided.

Definitions

Relapsing forms of multiple sclerosis

Included conditionsClinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease as specified in FDA labeling.

Population specifiedIndication applies to adults per FDA labeling; pediatric authorization may be considered when benefits outweigh risks (see policy notes).

Coverage limitationAll other indications outside these relapsing forms are considered experimental/investigational and not medically necessary.

Background

Teriflunomide (Aubagio) is indicated for the treatment of adults with relapsing forms of multiple sclerosis, which includes clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease. Continuation of therapy may be appropriate for members demonstrating disease stability or improvement while on treatment; pediatric (<18 years) authorization may be considered when benefits outweigh risks.