|
Ampyra
(dalfampridine)
tablets 10mg
|
60 tablets per
30 days
|
Not applicable
|
• 10 mg orally twice daily
|
|
Aubagio
(teriflunomide)
tablets 7mg
|
30 tablets
per 30 days
|
Not applicable
|
• 7 mg or 14 mg orally
once daily
|
|
Aubagio
(teriflunomide)
tablets 14mg
|
30 tablets
per 30 days
|
Not applicable
|
|
Avonex
(interferon beta-1a) prefilled syringe
30mcg/0.5mL
|
1 box
(4 syringes)
per 28 days
|
Not applicable
|
• The recommended dose
is 30 mcg
intramuscularly once
weekly
• To reduce the incidence
and severity of flu-like
symptoms Avonex may
be started at a dose of
7.5 mcg and the dose
increased by 7.5 mcg
each week for the next 3
weeks until the
recommended dose of
30 mcg is achieved.
|
|
Avonex
(interferon beta-
1a) pen
30mcg/0.5mL
|
1 box
(4 pens)
per 28 days
|
Not applicable
|
|
Bafiertam
(monomethyl
fumarate) 95mg
oral capsules
|
120 capsules
per 30 days
|
Not applicable
|
• The starting dose is
95mg twice a day orally
for 7 days. After 7 days
the dosage should be
increased to the
maintenance dosage of
190mg twice a day
orally.
|
|
Betaseron
(interferon beta-
1b) vial 0.3mg
|
14 vials
per 28 days
|
Not applicable
|
• The recommended
starting dose is 0.0625
mg (0.25 mL)
subcutaneously every
other day, with dose
increases over a six-
week period to the
recommended dose of
0.25 mg (1 mL) every
other day
|
|
Briumvi
(ublituximab-xiiy)
vial 150mg/6mL
|
3 vials
per 168 days
|
4 vials
per 15 days
|
• First infusion: 150 mg
• Second infusion: 450
mg administered two
weeks after the first
infusion
• Subsequent infusions:
450 mg every 24 weeks
(first subsequent
infusion is administered
24 weeks after the first
infusion)
|
|
Copaxone
(glatiramer
acetate)
prefilled syringe
20mg/mL
|
30 prefilled
syringes
per 30 days
|
Not applicable
|
• 20 mg subcutaneously
once daily
|
|
Copaxone
(glatiramer
acetate)
prefilled syringe
40mg/mL
|
12 prefilled
syringes
per 28 days
|
Not applicable
|
• 40 mg subcutaneously
three times weekly and
at least 48 hours apart
|
|
Extavia (interferon
beta-1b) vial 0.3mg
|
15 vials
per 30 days
|
Not applicable
|
• The recommended
starting dose is 0.0625
mg (0.25 mL)
subcutaneously every
other day, with dose
increases over a six-
week period to the
recommended dose of
0.25 mg (1 mL) every
other day.
|
|
Glatopa
(glatiramer
acetate) prefilled
syringe 20mg/mL
|
30 prefilled
syringes
per 30 days
|
Not applicable
|
• 20 mg subcutaneously
once daily
|
|
Glatopa (glatiramer
acetate) prefilled
syringe 40mg/mL
|
12 prefilled
syringes
per 28 days
|
Not applicable
|
• 40 mg subcutaneously
three times weekly and
at least 48 hours apart
|
|
Gilenya (fingolimod
hydrochloride)
capsules 0.25mg
|
30 capsules
per 30 days
|
Not applicable
|
• 0.5 mg orally once daily
in adults and pediatric
patients 10 years of age
and older weighing
more than 40 kg
• 0.25 mg orally once
daily for pediatric
patients 10 years of age
and older weighing less
than or equal to 40 kg
|
|
Gilenya (fingolimod
hydrochloride)
capsules 0.5mg
|
30 capsules
per 30 days
|
Not applicable
|
|
Kesimpta
(ofatumumab)
20 mg/0.4 mL
prefilled syringe
|
1 syringe
per 28 days
|
3 syringes
per 15 days
|
• 20mg subcutaneously
weekly for 3 weeks then
once monthly dosing
starting week 4.
|
|
Kesimpta
(ofatumumab)
20 mg/0.4 mL
prefilled
sensoready pen
|
1 pen
per 28 days
|
3 pens
per 15 days
|
|
Lemtrada
(alemtuzumab)
|
See Stand Alone Policy
|
|
Mavenclad
(cladribine)
tablets 10mg
|
20 tablets
per 301 days
|
Not applicable
|
• 3.5mg/kg divided into
two treatment courses
(1.75mg/kg per
treatment course).
Each treatment course
is divided into 2
treatment cycles.
• Maximum recommended
dose per cycle (110 kg
and above): 100 mg
|
|
Mayzent
(siponimod)
0.25mg tablets
starter pack
(for 2-mg dose)
|
12 tablets
per 5 days
|
Not applicable
|
• Titration to reach 2 mg
maintenance dosage:
° Day 1: 0.25mg
° Day 2: 0.25mg
° Day 3: 0.50mg
° Day 4: 0.75mg
° Day 5: 1.25mg
• Do not use the starter
pack for patients who will
be titrated to the 1-mg
maintenance dosage
|
|
Mayzent
(siponimod)
0.25mg tablets
starter pack
(for 1-mg dose)
|
7 tablets
per 4 days
|
Not applicable
|
• Titration to reach 1 mg
maintenance dosage:
° Day 1: 0.25mg
° Day 2: 0.25mg
° Day 3: 0.50mg
° Day 4: 0.75mg
• Do not use the starter
pack for patients who will
be titrated to the 2-mg
maintenance dosage
|
|
Mayzent
(siponimod)
0.25mg tablets
|
12 tablets
per 5 days
|
Not applicable
|
• Titration to reach 1 mg
maintenance dosage:
° Day 1: 0.25mg
° Day 2: 0.25mg
° Day 3: 0.50mg
° Day 4: 0.75mg
• Titration to reach 2 mg
maintenance dosage:
° Day 1: 0.25mg
° Day 2: 0.25mg
° Day 3: 0.50mg
° Day 4: 0.75mg
° Day 5: 1.25mg
|
|
Mayzent
(siponimod)
1mg tablets
|
30 tablets
per 30 days
|
Not applicable
|
• 1 mg daily after starter
pack
|
|
Mayzent
(siponimod)
2mg tablets
|
30 tablets
per 30 days
|
Not applicable
|
• 2 mg daily after starter
pack
|
|
Ocrevus
(ocrelizumab)
vial 300mg/10mL
|
2 vials
per 168 days
|
2 vials
per 15 days
|
Initial dose (two infusions):
• Infusion 1: 300 mg
• Infusion 2 (2 weeks later): 300 mg
Subsequent doses:
600 mg (one infusion) every
6 months (1st subsequent
dose is administered 6
months after Infusion 1 of
the initial dose)
|
|
Plegridy
(peginterferon
beta-1a) pen or
prefilled syringe
125mcg/0.5mL
|
1 carton
(2 pens or
prefilled
syringes)
per 28 days
|
Not applicable
|
• The recommended dose is
125 mcg intramuscularly
or subcutaneously every
14 days.
• Treatment initiation:
° Day 1: 63 mcg
° Day 15: 94 mcg
° Day 29 and every 14
days thereafter: 125
mcg (full dose)
|
|
Plegridy (peginterferon beta-1a) Starter Pack pen or prefilled syringe
|
1 Starter
Pack/1
Titration kit
(2 pens or
prefilled
syringes)
per 28 days
|
Not applicable
|
|
Plegridy
(peginterferon
beta-1a)
Titration kit
prefilled syringe for
intramuscular use
|
1 Titration kit
(2 prefilled
syringes)
per 28 days
|
Not applicable
|
|
Ponvory
(ponesimod)
Starter pack
|
1 Starter Pack
(14 tablets)
per 14 days
|
Not applicable
|
• The recommended dose is
20 mg taken orally once
daily starting on day 15.
• Treatment Initiation
° Days 1 and 2: 2 mg
° Days 3 and 4: 3 mg
° Days 5 and 6: 4 mg
° Day 7: 5 mg
° Day 8: 6 mg
° Day 9: 7 mg
° Day 10: 8 mg
° Day 11: 9 mg
° Days 12, 13, and 14:
10 mg
• Maintenance dose: 20 mg
daily starting on day 15
|
|
Ponvory
(ponesimod)
20 mg tablet
|
30 tablets
per 30 days
|
Not applicable
|
|
Rebif
(interferon beta-
1a) prefilled syringe
or autoinjector
22mcg/0.5mL
|
12 prefilled
syringes or
autoinjectors
(6 mL) per
28 days
|
Not applicable
|
• The recommended dose is
either 22 mcg or 44mcg
subcutaneously three
times weekly (at least 48
hours apart)
• Generally, patients should
be started at 20% of the
prescribed dose three
times weekly and
increased over a 4-week
period to the targeted
dose, either 22 mcg three
times weekly or 44 mcg
three times weekly.
• Titration schedule for a
22 mcg prescribed dose:
° Weeks 1 and 2
titration: 4.4mcg three
times weekly
° Weeks 3 and 4
titration: 11mcg three
times weekly
° Week 5 and after: 22
mcg three times
weekly
• Titration schedule for a
44 mcg prescribed dose:
° Weeks 1 and 2
titration: 8.8mcg three
times weekly
° Weeks 3 and 4
titration: 22mcg three
times weekly
° Week 5 and after: 44
mcg three times
weekly
|
|
Rebif (interferon
beta-1a) prefilled
syringe or
autoinjector
44mcg/0.5mL
|
12 prefilled
syringes or
autoinjectors
(6 mL) per
28 days
|
Not applicable
|
|
Rebif (interferon
beta-1a) titration
pack w/ prefilled
syringes or titration
pack w/
autoinjectors)
|
12 prefilled
syringes or
autoinjectors
(4.2 mL)
per 28 days
|
Not applicable
|
|
Tascenso ODT
(fingolimod lauryl
sulfate) tablets
0.25mg
|
30 tablets
per 30 days
|
Not applicable
|
• 0.5 mg orally once daily
for pediatric patients 10
years of age and older
weighing more than 40 kg
• 0.25 mg orally once daily
for pediatric patients 10
years of age and older
weighing less than or
equal to 40 kg
|
|
Tascenso ODT
(fingolimod lauryl
sulfate) tablets
0.5mg
|
30 tablets
per 30 days
|
Not applicable
|
|
Tecfidera (dimethyl fumarate) capsules 120mg
|
14 capsules per 28 days
|
56 per 84 days
Temporary dose reductions are permitted once every 84 days
|
• The starting dose is 120
mg orally twice a day.
After 7 days, the dose
should be increased to
the maintenance dose of
240 mg orally twice daily.
• Temporary dose
reductions to 120 mg
twice daily may be
considered for individuals
who do not tolerate the
maintenance dose.
Within 4 weeks, the
recommended dose of
240 mg twice daily
should be resumed.
|
|
Tecfidera
(dimethyl
fumarate)
capsules 240mg
|
60 capsules
per 30 days
|
Not applicable
|
|
Tecfidera (dimethyl
fumarate) 30-day
Starter Pack
|
60 capsules
per 30 days
|
Not applicable
|
|
Tysabri
(natalizumab)
|
See Stand Alone Policy
|
|
Vumerity (diroximel
fumarate) 30-day
Starter dose bottle
(bottle of 106
capsules) 231mg
|
106 capsules
per 30 days
|
Not applicable
|
• The starting dosage for
Vumerity is 231 mg twice
a day orally. After 7 days,
the dosage should be
increased to the
maintenance dosage of
462 mg (administered as
two 231 mg capsules)
twice a day orally.
• Temporary dosage
reductions to 231 mg
twice a day may be
considered for individuals
who do not tolerate the
maintenance dosage.
Within 4 weeks, the
recommended dosage of
462 mg twice a day
should be resumed.
|
|
Vumerity (diroximel
fumarate) 30-day
Maintenance dose
bottle (bottle of
120 capsules)
231mg
|
120 capsules
per 30 days
|
Not applicable
|
|
Zeposia (ozanimod)
|
See Stand Alone Policy
|
