Subject: Betaseron-Extavia 1840-A SGM P2021

Drug

BETASERON  (interferon beta-1b)

EXTAVIA  (interferon beta-1b)

Policy:

I.    INDICATIONS

The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.

FDA-Approved Indications
Betaseron and Extavia are indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

All other indications are considered experimental/investigational and not medically necessary.

II.  CRITERIA FOR INITIAL APPROVAL

A.   Relapsing forms of multiple sclerosis
      Authorization of 12 months may be granted to members who have been diagnosed with a relapsing form of multiple sclerosis
      (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse).

B.   Clinically isolated syndrome
      Authorization of 12 months may be granted to members for the treatment of clinically isolated syndrome of multiple sclerosis. 

III. CONTINUATION OF THERAPY    

For all indications: Authorization of 12 months may be granted for members who are experiencing disease stability or improvement while receiving Betaseron or Extavia.

IV.  OTHER CRITERIA

Members will not use Betaseron or Extavia concomitantly with other disease modifying multiple sclerosis agents (Note: Ampyra and Nuedexta are not disease modifying).

Place of Service:

Outpatient

The above policy is based on the following references:

1. Betaseron [package insert]. Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc.; March 2021.
2. Extavia [package insert]. Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc.; October 2020.
3. AHFS DI (Adult and Pediatric) [database online]. Hudson, OH: Lexi-Comp, Inc.; http://online.lexi.com/lco/action/index/dataset/complete_ashp [available with subscription]. Accessed (April 2021).

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

December 23, 2021