Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
natalizumab

Criteria Approval Period

Initial:  As third-line monotherapy for the treatment of relapsing-remitting multiple sclerosis (MS), diagnosed according to the current clinical criteria and magnetic resonance imaging (MRI) evidence, when prescribed by a neurologist from a designated MS clinic, for patients who meet ALL of the following criteria:

  1. Patient has failed to respond to full and adequate courses of treatment with at least two (2) other disease modifying therapies, OR has contraindications or intolerance to these therapies, AND
  2. Patient has had a significant increase in T2 lesion load compared to a previous MRI scan OR at least one gadolinium-enhancing lesion, AND
  3. Patient has had at least two (2) disabling attacks of MS in the previous one (1) year.

One Year

Renewal:  When prescribed by a neurologist from a designated MS clinic, for the treatment of patients with relapsing-remitting multiple sclerosis, a lack of neutralizing antibodies, AND who have demonstrated continued therapeutic benefit outweighing any potential risks, as shown by relapse rate, EDSS, MRI scan,  or overall clinical impression.

One Year

Practitioner Exemptions

None.

Special Notes

  • The current clinical criteria for the diagnosis of MS are the McDonald criteria, as of October 26, 2010.
  • An attack is defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 24 hours in the absence of fever, and preceded by stability for at least one (1) month.

Online Forms (PDF 544K)

Click on the link to complete a Special Authority request form.