Page 2 of 2 section b physician signature physician signature date fax completed form to. Give your patient the instructions for patients and patient consent information pages. Do not use if the medicine has changed colors or has particles in it. Prepare an injection only when you are ready to give it. Tecfidera dimethyl fumarate prescribing information and. Upon receipt of the completed form, prescription benefit coverage will be determined based on the benefit plans rules. Instructions for healthcare providers tecus0298 v9 0120. The information in this guide does not take the place of talking with your doctor or. In clinical trials, mri scans showed people taking avonex. Avonex helps most people with ms but it may have unwanted effects in a few people. I attest the information provided is true and accurate to the best of my knowledge. Avonex interferon beta1a medication precertification request. In some cases, the medical and pharmacy cards may be the same. Avonex express scripts prior authorization phone 18444248886 fax 18772515896.
If your doctor has recommended that you start avonex ps at a lower dose and gradually increase up to the full dose dose titration, please follow the instructions for use included in the. Medication guide avonex interferon beta1a including appendix with instructions for using avonex prefilled syringe please read this guide carefully before you start to use avonex avuhnecks and each time your prescription is refilled since there may be new information. Interferon beta1a is a 166 amino acid glycoprotein with a predicted molecular weight of approximately 22,500 daltons. Avonex is indicated for the treatment of relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease, and active secondary progressive disease, in adults. Do not use external heat sources, such as hot water, to warm avonex psavonex pen. It is produced by mammalian cells chinese hamster ovary cells into which the human interferon beta gene has been introduced. Full prescribing information 1 indications and usage tecfidera is indicated for the treatment of relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease, and active secondary progressive disease, in adults. Avostartgrip titration kit instructions for use avonex. Please complete the following questions and then fax this form to the toll free number listed below. Avonex prior authorization request form member information.
Gilenya patient assistance start gilenya fingolimod. Before your injection, avonex psavonex pen should be taken out of the refrigerator and allowed to warm to room temperature over 30 minutes. Plegridy is a prescription medicine used to treat relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease. Avonex is a prescription medicine used to treat relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease. Copaxone is contraindicated in patients with known hypersensitivity to glatiramer acetate or mannitol. The characteristics of the clinical course of ms may be classified into four categories. Interferon beta1a also interferon beta 1alpha is a cytokine in the interferon family used to treat multiple sclerosis ms. Be sure to include your email address in the space provided. If youre thinking about taking gilenya, this section was made just for. What is avonex interferon beta1a avonex is a prescription medicine used to treat relapsing forms of multiple sclerosis ms, to include clinically isolated. All avonex dosage forms are singleuse injection of reconstituted solution. Avonex is for the treatment of relapsing forms of multiple sclerosis ms. Learn how to get started on avonex, how to download the avonex start form, info on injection training, and the first steps to financial assistance support.
The avostartgrip is used for giving the week 1, 2, and 3. Just fill out this form and bring it to your health care professional. Patient authorization and betaplus enrollment form for. Avonex and rebif are the meds,difference is avonex is in the muscle and once a week,rebif is under the skin. Interferon beta1a is a 166 amino acid glycoprotein with a specific activity of approximately. To start your part d coverage determination request, you or your representative or your doctor or. Avonex and rebif are the brand names of the injectable medicine interferon beta1a, which is used to treat symptoms of relapsingremitting multiple sclerosis rrms. Read the medication guide and instructions for use provided by your pharmacist before you start using interferon beta1a and each time you get a refill. If you have completed a printed start form, fax the start form to 18554743067.
You selfinject avonex into a muscle once a week to reduce the number and severity of relapses. Ampyra patient support services center free 60 day trial. Patient name address city state zip home phone cell phone preferred time to call sex. Avonex interferon beta1a is a prescription medicine used to treat relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease, and active secondary progressive disease, in adults. Using the avonex prefilled syringe with the avostartgrip titration kit. Avonex is injected into a muscle, usually once weekly at bedtime, on the same day each week such as every monday. Your avonex dose may be titrated over 3 weeks by using avonex prefilled syringe with the avostartgrip titration kit. You have fewer relapses than you might have had with no treatment and any relapses you do have should be less severe avonex is a moderately effective category 1.
There is yet no solid evidence it provides any benefit against the sarsncov2 virus that causes the deadly respiratory pandemic, but studies are ongoing. Injections for 3timesaweek copaxone 40 mg must be at least 48 hours apart. Prior authorization prescriber fax form copaxone coverage. Copy both sides of the patients medical insurance card and pharmacy benefit card, if available. Getting your prescription the avonex start form is your key to. Avonex interferon beta 1a medication precertification request. The powder form of this medicine must be mixed with a liquid diluent before using it. Complete the rest of the start form and sign the prescriber authorization if available, copy both sides of the patients insurance card and pharmacy benefit card fax page 4 of the start form with copies of the cards mentioned above to 18555572478. Aubagio one to one start form authorization to share health information as part of one to one support services please read this page carefully and if you agree, sign and date where indicated in section 2 of the start form. Avonex is a prescription medicine used to treat relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease, and active secondary progressive disease, in adults. Nonformulary interferon beta1a avonex will be covered on the prescription drug benefit for 12 months when the following criteria are met. I have had a few site reactions,on created ab open sore,but that was my mistake,injected to low,plus i was on steroid infusions,so that slowed the healing process. Avonex interferon beta1a including appendix with instructions for using avonex vials please read this guide carefully before you start to use avonex avuhnecks and each time your prescription is refilled since there may be new i nformation. Avonex interferon beta1a medication precertification.
Full prescribing information 1 indications and usage copaxone is indicated for the treatment of relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease, and active secondary progressive disease, in adults. Apr 09, 2020 avonex is a form of a protein called beta interferon that occurs naturally in the body. Betaseron is the first fdaapproved medicine to reduce disease activity in patients. Sep 11, 2019 avonex is injected into a muscle, usually once weekly at bedtime, on the same day each week such as every monday. To reduce the incidence and severity of flulike symptoms that may occur when initiating avonex therapy at a dose of 30 micrograms, avonex may be started at a dose of 7. It reduces the number of relapses by about one third 30%, compared to taking placebo. By giving us your email address, you can stay up to date on. Avonex interferon beta1a is a 166 amino acid glycoprotein with a predicted molecular. Copaxone copay solutions program rules for copaxone glatiramer acetate injection 20 mgpatient eligibility, terms and conditions. Your medical treatment, payments, insurance enrollment, or eligibility for insurance benefits do not depend on your signing this form. Some claims have been made that interferons produce. Do not use avonex or diluent past the expiration date. Avonex is a form of a protein called beta interferon that occurs naturally in the body. To start your part d coverage determination request, you or your representative or your doctor or other prescriber should contact express scripts, inc esi.
Copaxone glatiramer acetate injection for relapsing ms. Avonex has been approved by the fda for treatment of a first multiple sclerosis attack. Avonex interferon beta1a rch powder for injection and solution for injection. A start form must be completed and faxed to the abovems program. Valid only for qualified patients with a valid prescription for copaxone 20 mgml.
I understand that the health plan or insurer its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the. Pharmacotherapy clinic staff can assist with completion of these forms and getting insurance approval. What is avonex goodrx avonex generic interferon beta 1a avonex clinical pharmacology avonex pen at rs 10934 unit id. Avonex is a disease modifying drug dmd for relapsing remitting ms. Studies in adults showed that gilenya reduced the frequency of relapses by 52% in a 1year study vs avonex, and by 54% in a 2year study vs placebo. Prior authorization prescriber fax form copaxone coverage determination this fax machine is located in a secure location as required by hipaa regulations. It is produced by mammalian cells, while interferon beta1b is produced in modified e. Before you start to prepare the injection, check the expiration date on the avonex and diluent vials. Dispense as written brand exchange permissible date. Forms are updated frequently and may be barcoded member information required provider information required member name. Interferon beta1a is under investigation as a potential treatment for the covid19 coronavirus disease as of april, 2020.
Interferon beta1a is a form of a protein that occurs naturally in the body. If patients or caregivers are to administer avonex, train them in the proper intramuscular injection technique and assess their ability to inject intramuscularly to ensure the proper administration of avonex. Avonex interferon beta1a drug medicine information. This program, operated by biogen the manufacturer of avonex, will start the process of obtaining the medication. Sometimes they are serious, most of the time they are not. Approximately 16% of patients exposed to copaxone 20 mg per ml compared to 4% of those on placebo, and approximately 2% of patients exposed to copaxone 40 mg per ml compared to none on placebo experienced. Only gilenya combines proven efficacy to cut multiple sclerosis ms relapses in half vs avonex, in a onceaday pill. Avonex interferon beta 1a injection treats multiple sclerosis ms in adults. If you are the caregiver of a child between the ages of 10 and 17 who is starting gilenya, please use the gilenya start form for children and bring it to your childs next doctor visit. This form may be used for nonurgent requests and faxed to 18005270531.
The first avonex injection should be performed under the supervision of an appropriately qualified health care professional. Simply fill out your portion of the form, and your health care professional will handle the rest. Copy both sides of the patients insurance card and pharmacy benefit card, if available. Serious side effects may happen right after or within. Criteriabased consultation prescribing program criteria. Avonex is a disease modifying drug for relapsing remitting ms. If youve made up your mind to ask your health care professional about gilenya, heres a great way to check another todo item off your list. Prescribed by a neurologist and diagnosis of relapsing form of multiple sclerosis ms on the problem list, including. Avonex psavonex pen should be stored in a refrigerator at 2c to 8c. You may call esi at 18444248886, 24 hours a day, 7 days a week, tty users.
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