Idiopathic hypersomnia: For patients age 16 years of age or older Trial and failure of 2 formulary stimulants (e.g., amphetamine/dextroamphetamine, methylphenidate) Diagnosis is supported by polysomnography and multiple sleep latency test. Multaq Multaq will be authorized when prescribed by, or in consultation with a cardiologist. If not Initial Approval: prescribed by or in consultation with a cardiologist, the following must be met: Indefinite Diagnosis is atrial fibrillation Patient has and failed amiodarone Age restriction: must be at 18 years old Multiple Sclerosis For patients who meet the following: Avonex, Betaseron, Avonex, Betaseron, Must be prescribed by a neurologist, or in consultation with a neurologist Extavia, Rebif, Copaxone, Extavia, Copaxone, Must be 18 years of age or older Gilenya, Tecfidera, Gilenya, Novantrone, Aubagio: Indefinite Gilenya, Tecfidera, In addition: Aubagio, mitoxantrone Gilenya, Tecfidera, Aubagio: Mitoxantrone: 3 months Failure of a compliant regimen of two formulary medications; such as, Avonex, Rebif, Documentation to support Betaseron, Extavia or Copaxone that prior to each dose patient is: Mitoxantrone: Assessed for cardiac Cumulative dose is less than 140 mg/m2 (if patient has received drug in the past) signs and symptoms by Failure of a compliant regimen of Avonex, Rebif, Betaseron, Extavia or Copaxone history, physical Failure of a complaint regimen of Tyasbri for 6 months examination and ECG. Quantitative reevaluation of LVEF
Idiopathic hypersomnia: For patients age 16 years of age or older Trial and failure of 2 formulary stimulants (e.g., amphetamine/dextroamphetamine, methylphenidate) Diagnosis is supported by polysomnography and multiple sleep latency test. Multaq Multaq will be authorized when prescribed by, or in consultation with a cardiologist. If not prescribed by or in consultation with a cardiologist, the following must be met: Diagnosis is atrial fibrillation Patient has and failed amiodarone Age restriction: must be at 18 years old Initial Approval: Indefinite Multiple Sclerosis Avonex, Betaseron, Extavia, Copaxone, Gilenya, Novantrone, Gilenya, Tecfidera, Aubagio, mitoxantrone For patients who meet the following: Must be prescribed by a neurologist, or in consultation with a neurologist Must be 18 years of age or older In addition: Gilenya, Tecfidera, Aubagio: Failure of a compliant regimen of two formulary medications; such as, Avonex, Rebif, Betaseron, Extavia or Copaxone Mitoxantrone: Cumulative dose is less than 140 mg/m2 (if patient has received drug in the past) Failure of a compliant regimen of Avonex, Rebif, Betaseron, Extavia or Copaxone Failure of a complaint regimen of Tyasbri for 6 months Avonex, Betaseron, Extavia, Rebif, Copaxone, Gilenya, Tecfidera, Aubagio: Indefinite Mitoxantrone: 3 months Documentation to support that prior to each dose patient is: Assessed for cardiac signs and symptoms by history, physical examination and ECG. Quantitative reevaluation of LVEF
MMIC-PA-SMI-Guidelines.docx