Interferon beta-1a (Avonex, Rebif/Rebif Rebidose)

Interferon beta-1a (Avonex®, Rebif®/Rebif® Rebidose®)

SELF ADMINISTRATION - INJECTABLE

Indication for Prior Authorization:

• Relapsing forms of Multiple Sclerosis (MS): 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

Coverage Criteria:

For diagnosis of MS:

• Patient has a documented diagnosis of relapsing forms of multiple sclerosis (MS) (e.g., clinically isolated syndrome, relapsing-remitting disease, secondary progressive disease, including active disease with new brain lesions); AND
• Prescribed by or in consultation with a neurologist AND
• Not used in combination with another disease-modifying therapy for MS 

Reauthorization Criteria:

For diagnosis of Multiple Sclerosis:

• Patient demonstrates positive clinical response to therapy (e.g., stability in radiologic disease activity, clinical relapses, disease progression) AND
• Not used in combination with another disease-modifying therapy for MS AND
• Prescribed by or in consultation with a neurologist 

Dosing:

For diagnosis of MS:

• Avonex®
  • Recommended adult dose: 30 micrograms once a week
  • To reduce the incidence and severity of flu-like symptoms that may occur when initiating Avonex® therapy at a dose of 30 micrograms, Avonex® may be started at a dose of 7.5 micrograms and the dose may be increased by 7.5 micrograms each week for the next three weeks until the recommended dose of 30 micrograms is achieved
• Rebif®/Rebif® Rebidose®
  • Recommended adult dose: 22 mcg or 44 mcg three times per week

Coverage Duration:

• Initial: 1 year
• Reauthorization: 1 year

Authorization is Not Covered for the Following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.

Additional Information:

• Avonex®: Warnings for depression, suicide, and psychotic disorders, hepatic injury, anaphylaxis, congestive heart failure, decreased peripheral blood counts, thrombotic microangiopathy, seizures, autoimmune disorders
• Rebif®/Rebif® Rebidose®: Warnings for depression and suicide, hepatic injury, anaphylaxis, injection site reactions including necrosis, decreased peripheral blood counts, thrombotic microangiopathy, seizures
• Pregnancy: Data from a large population-based cohort study, as well as other published studies over several decades, have not identified a drug-associated risk of major birth defects with the use of interferon beta products during early pregnancy
• Lactation: Limited published literature has described the presence of interferon beta-1a products in human milk at low levels. There are no data on the effects of interferon beta-1a on milk production
• Safety and effectiveness in pediatric patients have not been established

Review History:

• 12/1/14- Annual review
• 11/17/20- Class review, format and criteria updated
• 6/1/2024 (policy effective date)- RRT MS update, added criteria point to not use in combination (P&T 5/20/2024) (P&T Meeting May)

References:

• Avonex [package insert]. Cambridge (MA): Biogen Inc.; 2020.
• OptumRX Therapeutic Class Overview – Multiple Sclerosis Agents.  Publication Date:  June 22, 2020.
• Rebif [package insert]. Rockland (MA): EMD Serono, Inc; 2020.