Aetna: Briumvi Payer Policy (Beta Access)

TABLE OF CONTENTS

• Medicare Part B
  
• Commercial

 MEDICARE PART B

Initial Approval Criteria

• 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). 
• Clinically Isolated Syndrome Authorization of 12 months may be granted to members for the treatment of clinically isolated syndrome of multiple sclerosis. 

Continuation Criteria

Authorization for 12 months may be granted when all of the following criteria are met: 

• The member is currently receiving therapy with Briumvi. 
• Briumvi is being used to treat an indication enumerated in Section II. 
• The member is receiving benefit from therapy. 

Sources: 

https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/Briumvi-5738-A-Aetna-MedB.pdf

https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/Multiple-sclerosis-1017-AMBST.pdf

COMMERCIAL

Other Pertinent Information

• Members will not use Briumvi concomitantly with other disease modifying multiple sclerosis agents 
  • (Note: Ampyra and Nuedexta are not disease modifying).
• Authorization may be granted for pediatric members less than 18 years of age when benefits outweigh risks.

Initial Approval Criteria

Aetna considers ublituximab-xiiy (Briumvi) medically necessary for the following indications when criteria are met:

• Relapsing forms of multiple sclerosis - for 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); or
• Clinically isolated syndrome (CIS) - for treatment of clinically isolated syndrome of multiple sclerosis. Aetna considers all other indications as experimental, investigational, or unproven.

Continuation Criteria:

• Aetna considers continuation of ublituximab-xiiy (Briumvi) therapy medically necessary granted for members who are experiencing disease stability or improvement while receiving Briumvi. 

Sources:

• https://www.aetna.com/cpb/medical/data/200_299/0264.html