CurrentPremera BluecrossPolicy N/A

Pharmacotherapy of Multiple Sclerosis

Coverage and medical necessity criteria for disease-modifying drugs used to treat relapsing forms of multiple sclerosis for Premera Bluecross members, with formulary-specific sections and quantity/dose limits.

Policy Summary

PayerPremera Bluecross

PolicyPharmacotherapy of Multiple Sclerosis

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document prior trial failure or intolerance to specified generics plus EDSS and neurologist involvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3formulary sections

EDSS < 6EDSS threshold

14max kits per 30 days

30teriflunomide tablets/30d

CYP2C9*3/*3siponimod genotype

Coverage and Medical Necessity Criteria

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Initial Medical Necessity Criteria — Section 1 (Open/Preferred/Select and no pharmacy benefit)

Covered when ALL of the following are met for the specified drug and formulary section

General RMS drug criteria (applicable across many agents): Diagnosis of relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing-remitting disease, active secondary progressive disease where specified) AND medication is prescribed by or in consultation with a neurologist or physician specializing in MS AND medication is not used concurrently with other MS disease-modifying drugs (unless otherwise specified) AND Expanded Disability Status Scale (EDSS) is less than the threshold specified for the drug (commonly < 6).

Agent-specific additional requirements: Agent-specific requirements when listed (examples include prior trial of a generic alternative or other DMD, genotype testing, age limits, and product-specific dose/quantity limits).

See individual agent sections for specifics.

Escalation requirement for certain high-cost agents: For some agents (e.g., cladribine/Mavenclad) there must be documented inadequate response to one or more disease-modifying drugs indicated for MS (examples listed in policy).

See agent-specific nodes.

β-interferons (Essentials formulary examples: Avonex, Rebif, Plegridy, Betaseron)

Covered when ALL of the following are met

Interferon class criteria: Individual has EDSS < 6 AND β‑interferons are not used concurrently with other MS disease‑modifying drugs AND medication is prescribed by or in consultation with a neurologist or MS specialist AND product-specific quantity limits apply (examples vary by product).EDSS < 6

Quantity examples in policy: Avonex/Rebif/Plegridy/Betaseron limits differ; Betaseron: 14 kits/30 days; some formulations limited to 4 pens/syringes/30 days.

Glatiramer products (generic glatiramer/Glatopa/Copaxone)

Covered when ALL of the following are met

Glatiramer criteria: Individual has EDSS < 6 AND glatiramer products are not used concurrently with other MS disease‑modifying drugs AND medication is prescribed by or in consultation with a neurologist or MS specialist AND quantity limits depend on strength (20 mg/mL: 30 syringes/30 days; 40 mg/mL: 12 syringes/30 days).EDSS < 6

For Copaxone brand, there is a step requirement: documented inadequate response or intolerance to generic glatiramer/Glatopa of the same strength before Copaxone.

Fumarates and analogues (generic dimethyl fumarate, Tecfidera, Bafiertam, Vumerity)

Covered when ALL of the following are met

Fumarate criteria: Individual has EDSS < 6 AND fumarate agents are not used concurrently with other MS disease‑modifying drugs AND medication is prescribed by or in consultation with a neurologist or MS specialist AND dose/quantity limits apply (examples: Tecfidera ≤480 mg/day; Bafiertam 380 mg/day; Vumerity 924 mg/day) AND for some branded agents there must be documented inadequate response or intolerance to generic dimethyl fumarate prior to approval.EDSS < 6

Step requirement: trial of generic dimethyl fumarate for 3 months with inadequate response or intolerance is referenced for some branded fumarates.

Sphingosine-1-phosphate receptor modulators (fingolimod, siponimod, ozanimod, ponesimod)

Covered when ALL of the following are met

S1P modulators criteria: Individual meets EDSS threshold (generally EDSS < 6; Mayzent/siponimod requires EDSS < 7) AND medication is not used concurrently with other MS DMDs AND medication is prescribed by or in consultation with a neurologist or MS specialist AND age/genotype limits apply where specified (e.g., generic fingolimod: age ≥10 years; Mayzent: documented NOT CYP2C9*3/*3) AND dose/quantity limits apply (examples: fingolimod 0.5 mg/day; Ponvory 2 mg/day; Zeposia 0.92 mg/day; typical quantity limits 30 tablets/30 days).EDSS < 6 (Mayzent < 7)

See product-specific dosing and age/genotype requirements.

CD20-directed antibodies and purine antimetabolites (ofatumumab/Kesimpta; cladribine/Mavenclad)

Covered when ALL of the following are met

CD20/cladribine criteria: Kesimpta (ofatumumab): individual is aged ≥18 years AND EDSS threshold applies AND Kesimpta is not used concurrently with other MS DMDs AND medication is prescribed by or in consultation with a neurologist or MS specialist. Cladribine (generic and Mavenclad): EDSS threshold applies AND medication is not used concurrently with other MS DMDs AND there is documented inadequate response to one or more listed disease‑modifying drugs AND treatment/course limits apply (limited number of courses/pens as specified).Age ≥18 for Kesimpta; EDSS thresholds per product

Cladribine requires prior inadequate response to one or more listed DMDs and is limited to specified treatment courses.

Medical Necessity — Relapsing Multiple Sclerosis (RMS)

Covered when ALL of the following are met for Individual/Small Group/Student ISHIP METALLIC Formulary Plans (Rx Plans M1, M2, and M4):

Plan restriction: Member is enrolled in Individual/Small Group/Student ISHIP METALLIC Formulary Plans (Rx Plan M1, M2, or M4).

Applies to Section 3 plans only.

Prescriber requirement: Medication is prescribed by or in consultation with a neurologist or physician who specializes in the treatment of multiple sclerosis.

Prescriber specialty is required for coverage.

Quantity limit: Quantity is limited to 14 kits per 30 days.<=14 kits per 30 days

Applies specifically to RMS kits for these formulary plans.

Plan-specific quantity-limited coverage

Covered when within plan-specific quantity limits

Plan and quantity conditions: Member is enrolled in Individual/Small Group/Student ISHIP METALLIC Formulary Plans (Rx Plan M1, M2, or M4) AND quantity does not exceed 14 kits per 30 days.14 kits per 30 days

Applies to RMS kit-based coverage in Section 3 plans.

Plegridy (interferon-β1a)

Plegridy (interferon-β1a) coverage conditions

Plegridy medical necessity criteria: Plegridy may be considered medically necessary for relapsing forms of MS when: EDSS < 6 AND beta‑interferons are not used concurrently with other MS DMDs AND medication is prescribed by or in consultation with a neurologist or MS specialist AND quantity is limited to 2 syringes or pens per 30 days.quantity=2 syringes/pens per 30 days

Rebif (interferon-β1a)

Rebif (interferon-β1a) coverage conditions

Rebif medical necessity criteria: Rebif may be considered medically necessary for relapsing forms of MS when: EDSS < 6 AND beta‑interferons are not used concurrently with other MS DMDs AND medication is prescribed by or in consultation with a neurologist or MS specialist.EDSS < 6

Quantity limits referenced in product sections of policy.

Glatiramer, Glatopa

Glatiramer products coverage conditions

Glatiramer (Glatopa) criteria: Glatiramer or Glatopa may be considered medically necessary for relapsing forms of MS when: EDSS < 6 AND not used concurrently with other MS disease‑modifying drugs AND prescribed by/consultation with neurologist or MS specialist AND quantity limits: 20 mg/mL syringe = 30 syringes/30 days; 40 mg/mL syringe = 12 syringes/30 days.20mg=30 syringes/30d;40mg=12 syringes/30d

Copaxone (glatiramer)

Copaxone coverage conditions

Copaxone criteria: Copaxone may be considered medically necessary when: EDSS < 6 AND Copaxone is not used concurrently with other MS DMDs AND there is documented inadequate response to or intolerance of generic glatiramer or Glatopa of the same strength AND medication is prescribed by or in consultation with a neurologist or MS specialist AND quantity limits apply (20 mg/mL: 30 syringes/30 days; 40 mg/mL: 12 syringes/30 days).EDSS < 6

Step requirement precedes Copaxone brand use.

Teriflunomide (Aubagio / generic)

Dihydroorotate dehydrogenase inhibitor / teriflunomide coverage conditions

Teriflunomide/Aubagio/generic criteria: Aubagio (teriflunomide) and generic teriflunomide may be considered medically necessary for relapsing forms of MS when: EDSS < 6 AND there has been documented inadequate response to or intolerance of specified alternatives (references include dimethyl fumarate and/or other agents) AND medication is prescribed by or in consultation with a neurologist or MS specialist AND quantity is limited to 30 tablets per 30 days.quantity=30 tablets/30 days; EDSS<6

Multiple repeated references in policy detail step and quantity limits.

Medical Necessity for Relapsing Multiple Sclerosis (RMS)

Covered when ALL of the following are met:

RMS coverage criteria: 1) Diagnosis: relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing-remitting, and active secondary progressive disease where referenced). 2) The individual must have EDSS < 6. 3) Documented inadequate response to or intolerance of generic dimethyl fumarate. 4) Aubagio (teriflunomide) is not used concurrently with other MS DMDs. 5) Medication is prescribed by or in consultation with a neurologist or physician who specializes in MS. 6) Quantity limit: 30 tablets per 30 days (where applicable).EDSS < 6; quantity=30 tablets/30 days

Document prior therapy failures and prescriber specialty; applies to specified Rx plans.

Medical Necessity — Relapsing Multiple Sclerosis (RMS)

Covered when ALL of the following are met

Relapsing Multiple Sclerosis (RMS): Patient has relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting MS, or active secondary progressive disease).

Prior therapy or intolerance: Documented inadequate response to or intolerance of generic dimethyl fumarate OR documented inadequate response to or intolerance of generic teriflunomide where specified.

Prescriber: Medication is prescribed by or in consultation with a neurologist or physician who specializes in treatment of multiple sclerosis.

EDSS requirement: Expanded Disability Status Scale (EDSS) of less than 6 when specified.EDSS < 6

Medical Necessity - Relapsing Multiple Sclerosis (RMS)

Covered when ALL of the following are met

Indication: Medication is for treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome and relapsing‑remitting MS (may include active secondary progressive disease where specified).

Prior therapy: Documented inadequate response to or intolerance of generic dimethyl fumarate where required and documented inadequate response to or intolerance of generic teriflunomide where required.

Prescriber: Medication is prescribed by or in consultation with a neurologist or physician who specializes in treatment of multiple sclerosis.

Quantity limit: Quantity is limited to 30 tablets per 30 days for oral teriflunomide (generic).30 tablets/30 days

Medical necessity criteria

Covered when ALL of the following are met

Indication: Treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome and relapsing‑remitting MS.

Prior therapy/step: There has been documented inadequate response to or intolerance of generic dimethyl fumarate (and where referenced inadequate response/intolerance to generic teriflunomide for subsequent agents).

Prescriber: Medication is prescribed by or in consultation with a neurologist or physician who specializes in treatment of multiple sclerosis.

Quantity limit: Quantity is limited to 30 tablets per 30 days for oral teriflunomide; syringe presentations have separate limits (20 mg/mL: 30 syringes; 40 mg/mL: 12 syringes).30 tablets/30 days

Medical Necessity — Generic teriflunomide

Covered when ALL of the following are met

Indication: For treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome and relapsing‑remitting MS.

Prescriber: Medication is prescribed by or in consultation with a neurologist or physician who specializes in the treatment of multiple sclerosis.

Quantity Limit: Quantity is limited to 30 tablets per 30 days for generic teriflunomide.30 tablets/30 days

Medical Necessity — Related DHODH inhibitor injectable

Covered when ALL of the following are met (related DHODH inhibitor injectable products)

Prior therapy: Documented inadequate response to or intolerance of generic teriflunomide (and where referenced generic dimethyl fumarate) is required for the related DHODH inhibitor injectable section.

EDSS: Patient has an EDSS of less than 6 where specified for that product.EDSS < 6

Quantity Limits (syringe): 20 mg/mL syringe: 30 syringes per 30 days; 40 mg/mL syringe: 12 syringes per 30 days.

Applies to injectable presentations referenced in Section 3.

Medical Necessity — Relapsing Multiple Sclerosis (RMS)

Covered when ALL of the following are met:

RMS indication: Indication is relapsing forms of multiple sclerosis (includes clinically isolated syndrome, relapsing-remitting, and active secondary progressive disease where referenced).

EDSS requirement: The individual must have an Expanded Disability Status Scale (EDSS) of less than 6.EDSS < 6

Prior therapy/step therapy: There has been documented inadequate response to or intolerance of generic dimethyl fumarate (some sections also reference inadequate response/intolerance to generic teriflunomide for other agents).

Specialist prescriber: Medication is prescribed by or in consultation with a neurologist or physician who specializes in treatment of multiple sclerosis.

Medical necessity — teriflunomide / DHODH inhibitor

Covered when ALL of the following are met

Relapsing MS diagnosis: Diagnosis of relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing-remitting).

Prior therapy failure/intolerance: Documented inadequate response to or intolerance of generic dimethyl fumarate (and where specified, inadequate response/intolerance to generic teriflunomide for certain agents).

Prescriber specialty: Medication is prescribed by or in consultation with a neurologist or physician who specializes in treatment of multiple sclerosis.

No concurrent MS DMDs: Aubagio (teriflunomide) is not used concurrently with other MS disease‑modifying drugs.

Medical necessity for teriflunomide (Aubagio)

Covered when ALL of the following are met

Population: Individual has relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing-remitting, or active secondary progressive disease).

Disability threshold: Expanded Disability Status Scale (EDSS) of less than 6.EDSS < 6

Prior therapy/step therapy: Documented inadequate response to or intolerance of generic dimethyl fumarate (and in some statements, inadequate response/intolerance to generic teriflunomide).

Prescriber: Medication is prescribed by or in consultation with a neurologist or physician who specializes in MS.

Medical necessity for teriflunomide (Aubagio) - Relapsing Multiple Sclerosis (RMS)

Covered when ALL of the following are met

Relapsing MS coverage prerequisites: 1) Diagnosis: relapsing forms of multiple sclerosis (including clinically isolated syndrome and relapsing‑remitting disease). 2) Documented inadequate response to or intolerance of required prior therapy (examples include generic dimethyl fumarate and/or generic teriflunomide where specified). 3) Medication is prescribed by or in consultation with a neurologist or physician who specializes in MS. 4) Aubagio (teriflunomide) is not used concurrently with other MS DMDs. 5) Quantity limits apply (30 tablets/30 days for oral; syringe-based formulations listed with separate limits).quantity limits apply

EDSS < 6 is required for certain indications as noted.

Medical necessity criteria

Covered when ALL of the following are met

Primary coverage criteria: 1) Diagnosis of relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease). 2) EDSS less than 6. 3) Documented inadequate response to or intolerance of generic dimethyl fumarate. 4) Documented inadequate response to or intolerance of generic teriflunomide when required by plan wording. 5) Teriflunomide (Aubagio) is not used concurrently with other MS DMDs. 6) Medication is prescribed by or in consultation with a neurologist or physician who specializes in MS. 7) Quantity limits adhered to (30 tablets/30 days for oral; syringe limits for injectable formulations).

Criteria assembled from repeated policy statements.

Concurrent use of β‑interferons (e.g., Avonex, Rebif, Plegridy, Betaseron) or other listed multiple sclerosis disease‑modifying therapies with another MS disease‑modifying drug is explicitly not allowed. The policy requires that β‑interferons not be used concurrently with other MS disease‑modifying drugs as a condition of medical necessity, and medications must be prescribed by or in consultation with a neurologist or physician who specializes in MS.

The policy excludes concurrent use of two disease‑modifying drugs for multiple sclerosis when individual drug sections prohibit combination therapy. Several agent‑specific criteria explicitly state that products (including interferons and teriflunomide/Aubagio) are not to be used concurrently with other MS disease‑modifying drugs; requests documenting concurrent DMTs are subject to denial under the policy.

Dose, Quantity Limits, and EDSS Thresholds

Dose/Quantity limits examples

Bafiertam (example)380 mg per day (190 mg twice daily)

Tecfidera (dimethyl fumarate)≤480 mg per day (240 mg twice daily)

Fingolimod (Gilenya) dose cap0.5 mg per day

Mayzent (siponimod) treatment coursesLimited to 2 treatment courses; dose capped at 2 mg per day

Expanded Disability Status Score (EDSS)

General EDSS requirementMost drugs require Expanded Disability Status Score (EDSS) less than 6

Mayzent (siponimod)Requires EDSS less than 7

Policy use of EDSSEDSS is used as an eligibility threshold for multiple MS therapies

Dose limits

Tecfidera (dimethyl fumarate)Dose limit: 480 mg per day (240 mg twice daily)

BafiertamDose limit: 380 mg per day (190 mg twice daily)

Vumerity (diroximel fumarate)Dose limit: 924 mg per day (462 mg twice daily)

Gilenya (fingolimod)Dose limit: 0.5 mg per day

Quantity limit

Plan-specific kit limit14 kits per 30 days (Individual/Small Group/Student ISHIP METALLIC: Rx Plans M1, M2, M4)

ApplicabilityApplies to Relapsing Multiple Sclerosis (RMS) for specified formulary plans

Documentation notePrescriptions should demonstrate dispensing does not exceed 14 kits per 30 days for applicable plans

Quantity limit — plan-specific (repeat)

Quantity limit (repeat)14 kits per 30 days (Individual/Small Group/Student ISHIP METALLIC: Rx Plans M1, M2, M4)

Plan scopeLimit documented repeatedly across Section 3 for the listed Rx plans

Denial riskRequests exceeding 14 kits per 30 days may be denied

EDSS threshold

Common EDSS thresholdEDSS < 6 for listed agents and indications

PurposeUsed as an eligibility threshold for multiple MS therapies

Referenced across sectionsEDSS < 6 repeated in multiple formulary sections and drug-specific entries

Quantity limit (tablets)

Tablet quantity limit (oral)30 tablets per 30 days

Applies toOral teriflunomide and other oral formulations where specified

Repetition30 tablets per 30 days repeated throughout multiple sections

Quantity limit (syringes)

20 mg/mL syringe limit30 syringes per 30 days

40 mg/mL syringe limit12 syringes per 30 days

Applies toGlatiramer injectable presentations and related DHODH inhibitor injectables where listed

Quantity limit (oral)

Oral teriflunomide tablet limit30 tablets per 30 days

Coverage contextGeneric teriflunomide and Aubagio referenced with 30 tablets per 30 days limit

Repeated statementLimit reiterated across multiple chunks for Section 3

Quantity limit (syringe 20 mg/mL)

20 mg/mL syringe30 syringes per 30 days

ContextListed for injectable DHODH inhibitor presentations and glatiramer syringes

PlanApplied within specified formulary sections (often Section 3: Rx Plans M1, M2, M4)

Quantity limit (syringe 40 mg/mL)

40 mg/mL syringe12 syringes per 30 days

ContextApplied to higher‑strength syringe formulations (e.g., glatiramer 40 mg/mL)

Repeated across documentLimit reiterated in multiple sections for Section 3 formulary plans

Oral teriflunomide quantity limit

Oral teriflunomide (Aubagio/generic)Quantity limited to 30 tablets per 30 days

ApplicabilityReferenced for generic teriflunomide in Section 3 and other sections where teriflunomide is covered

DocumentationQuantity limit repeatedly emphasized in policy text

Syringe quantity limits

Syringe quantity limits20 mg/mL: 30 syringes per 30 days; 40 mg/mL: 12 syringes per 30 days

Applies toInjectable presentations referenced in DHODH inhibitor and glatiramer sections

Plan-specific noteLimits specified within Section 3 (Rx Plans M1, M2, M4)

Prior Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required and Documentation Expectations

Prior authorization is required for multiple sclerosis disease-modifying therapies and approval is contingent on documentation of the criteria below. Provide complete clinical documentation with the PA request: diagnosis (relapsing forms of MS), current Expanded Disability Status Scale (EDSS) score, prior therapy history including dates/doses and reason for discontinuation (inadequate response or intolerance), prescriber specialty (neurologist or MS specialist) or documentation of consultation with one, and any genetic testing or contraindication testing when required by the drug-specific criteria. Failure to document required prior therapies (for example, a trial of generic dimethyl fumarate or generic teriflunomide when required) or failure to document inadequate response/intolerance may result in denial.

Required documentation: diagnosis, EDSS, prior medication trials with dates and reasons for failure/intolerance, prescriber specialty or consultation note, relevant test results (e.g., CYP2C9 genotype when required).
Prescriber requirement: medication must be prescribed by or in consultation with a neurologist or physician who specializes in MS.
EDSS threshold: many pathways require EDSS < 6 (or < 7 for specific agents); if EDSS meets or exceeds the policy threshold, criteria are not met.

Denial Risk

Quantity Limit Denial Risk

Quantity limits in the formulary are strictly enforced. Requests that exceed the plan-specific quantity limits are at high risk for denial unless clinical justification and documentation supporting medical necessity for the higher quantity are provided.

Individual/Small Group/Student ISHIP METALLIC (Rx M1, M2, M4): quantity limited to 14 kits per 30 days for applicable agents.
Many oral/injectable agents: common limits include 30 tablets/capsules per 30 days or specified syringe counts (e.g., 20 mg/mL: 30 syringes/30 days; 40 mg/mL: 12 syringes/30 days).
Requests exceeding quantity limits without justification may be denied.

Step Therapy

Step Therapy Requirement for Copaxone

Step therapy is required for some branded agents. For Copaxone (branded glatiramer) a documented trial and inadequate response or intolerance to generic glatiramer (or Glatopa) is required before Copaxone will be covered.

Copaxone requires prior trial of generic glatiramer or Glatopa with documentation of inadequate response or intolerance.
Provide dates, dose, and clinical rationale for failure/intolerance of the generic product.

Step Therapy

Prior Therapy Failure (Generic-First) and Step Therapy Notes

Many therapies require documented prior therapy failure (generic-first requirement). A common required prior trial is generic dimethyl fumarate; for some agents generic teriflunomide is also required. Lack of documentation of these prior trials or of inadequate response/intolerance will trigger denial.

Documented inadequate response or intolerance to generic dimethyl fumarate is required where specified.
Where policy specifies, documented inadequate response or intolerance to generic teriflunomide is also required.
Include treatment duration (e.g., 3 months for dimethyl fumarate where specified), specific adverse effects or clinical measures of inadequate response, and dates of therapy.

Denial Risk

Triggers for Potential Denial

Triggers for potential denial include: concurrent use of multiple MS disease-modifying therapies, failure to meet EDSS thresholds, missing prescriber specialty documentation, missing or incomplete prior therapy documentation, and requests exceeding quantity limits without justification.

Concurrent MS DMDs: policy expressly disallows concurrent use of β-interferons or other DMDs with the requested agent; concurrent therapy may lead to denial.
EDSS not meeting required threshold (e.g., EDSS ≥ policy limit) will trigger denial.
Missing documentation of inadequate response/intolerance to required prior agents will trigger denial.
Prescriptions not from or not documented as consulted with a neurologist/MS specialist may be denied.

Documentation Required

Required Clinical Documentation and Prescriber Specialty

Provide specialist involvement and specific clinical documentation to support medical necessity. Approval depends on clear demonstration that step therapy and other program requirements have been met.

Prescriber specialty: include note that medication is prescribed by or in consultation with a neurologist or MS specialist; include contact/name of consulted specialist if prescriber is not a specialist.
Required clinical documentation: diagnosis, EDSS score, prior therapy history with outcomes (response/intolerance), relevant lab or genotype testing when specified (e.g., CYP2C9), and dose/quantity requested.
If requesting an exception to step therapy or quantity limits, submit supporting clinical rationale and relevant records.

Clinical Background

Multiple sclerosis (MS) is an immune‑mediated disease in which the body's immune system reacts to and damages nerve cells in the brain and spinal cord, producing variable neurologic symptoms. This policy addresses disease‑modifying pharmacotherapies for relapsing forms of MS and sets coverage and medical necessity requirements (for example, diagnosis of relapsing forms of MS, prescriber specialty, Expanded Disability Status Scale thresholds, prior‑therapy requirements, and prohibitions on concurrent disease‑modifying therapy).

Key Terms and Abbreviations

Multiple sclerosis (MS)

Definition — Multiple sclerosis (MS)A disease in which the body's immune system reacts to and damages nerve cells in the brain and spinal cord, causing variable neurological symptoms.

Clinical manifestationsSymptoms can include vision problems, numbness, tingling, and muscle weakness

ContextPolicy addresses disease-modifying pharmacotherapies for relapsing forms of MS

Expanded Disability Status Score (EDSS)

EDSS — policy roleExpanded Disability Status Score (EDSS) is a disability scale used in the policy to determine eligibility for multiple MS therapies

Common thresholdDocument commonly requires EDSS less than specified thresholds (often <6)

Documentation requirementEDSS score must be documented in prior authorization/clinical documentation

Expanded Disability Status Score (EDSS) — thresholds

Typical thresholdsEDSS < 6 for most therapies; Mayzent (siponimod) requires EDSS < 7

Use across formulary sectionsEDSS thresholds are referenced across Sections 1–3 and drug-specific entries

Denial riskIf EDSS is 6 or greater, criteria for some indications are not met and may lead to denial

RMS — abbreviation and context

AbbreviationRMS = Relapsing Multiple Sclerosis

Included disease formsRMS encompasses clinically isolated syndrome and relapsing‑remitting disease where referenced

Policy contextRMS is the primary indication referenced for many coverage criteria in this policy

Relapsing forms of multiple sclerosis

Relapsing forms includedIncludes clinically isolated syndrome, relapsing‑remitting MS, and active secondary progressive disease where specified

Policy usageThis definition is used to define eligible diagnoses for disease‑modifying therapies

Referenced in criteriaAppears in multiple coverage criteria nodes across sections

Dihydroorotate Dehydrogenase Inhibitor

Pharmacologic classDihydroorotate Dehydrogenase (DHODH) inhibitor — referenced for teriflunomide

Agent exampleTeriflunomide (Aubagio/generic) is a DHODH inhibitor referenced in coverage criteria

Quantity limit tie-inDHODH inhibitor sections reference tablet and syringe quantity limits (e.g., 30 tablets/30 days; syringe limits)

Policy Summary

PayerPremera Bluecross

PolicyPharmacotherapy of Multiple Sclerosis

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document prior trial failure or intolerance to specified generics plus EDSS and neurologist involvement.

SourceLink

On This Page

Quantity limits: Quantity limited to product‑specific amounts (oral: 30 tablets/30 days; syringes: 20 mg/mL = 30 syringes/30 days; 40 mg/mL = 12 syringes/30 days).see thresholds

Concurrent therapy: Aubagio (teriflunomide) is not used concurrently with other MS disease‑modifying drugs as stated in the policy.

EDSS requirement: For some relapsing/active secondary progressive indications, EDSS must be less than 6.EDSS < 6

Concomitant therapy: Aubagio (teriflunomide) is not used concurrently with other MS DMDs.

Disability requirement: For certain presentations, EDSS must be less than 6.EDSS < 6

Concurrent therapy: Aubagio (teriflunomide) is not to be used concurrently with other MS disease‑modifying drugs.

Quantity limits apply (e.g., 30 tablets per 30 days for oral; syringe formulations have specified syringe limits: 20 mg/mL = 30 syringes/30 days; 40 mg/mL = 12 syringes/30 days).30 tablets/30 days; 20 mg/mL: 30 syringes/30 days; 40 mg/mL: 12 syringes/30 days

EDSS requirement for certain presentations: For remitting disease and active secondary progressive disease, the individual must have an EDSS of less than 6.EDSS < 6

Quantity limits: Adhere to quantity limits: oral tablets limited to 30 tablets per 30 days; injectable syringes limited as listed (20 mg/mL: 30 syringes/30 days; 40 mg/mL: 12 syringes/30 days).

Quantity limits: Quantity limited to 30 tablets per 30 days for tablets (syringe/other formulations have specified syringe limits).30 tablets/30 days

No concurrent DMT: Aubagio (teriflunomide) is not used concurrently with other MS disease‑modifying drugs.