This program, operated by biogen the manufacturer of avonex, will start the process of obtaining the medication. In clinical trials, mri scans showed people taking avonex. Pharmacotherapy clinic staff can assist with completion of these forms and getting insurance approval. 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. There is yet no solid evidence it provides any benefit against the sarsncov2 virus that causes the deadly respiratory pandemic, but studies are ongoing. Be sure to include your email address in the space provided. Sometimes they are serious, most of the time they are not. Avonex has been approved by the fda for treatment of a first multiple sclerosis attack. 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. Avonex interferon beta 1a injection treats multiple sclerosis ms in adults. 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. You selfinject avonex into a muscle once a week to reduce the number and severity of relapses. Valid only for qualified patients with a valid prescription for copaxone 20 mgml. 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.
Copy both sides of the patients insurance card and pharmacy benefit card, if available. What is avonex interferon beta1a avonex is a prescription medicine used to treat relapsing forms of multiple sclerosis ms, to include clinically isolated. Ampyra patient support services center free 60 day trial. Using the avonex prefilled syringe with the avostartgrip titration kit. This form may be used for nonurgent requests and faxed to 18005270531. The information in this guide does not take the place of talking with your doctor or.
Before you start to prepare the injection, check the expiration date on the avonex and diluent vials. 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. Injections for 3timesaweek copaxone 40 mg must be at least 48 hours apart. Interferon beta1a is a 166 amino acid glycoprotein with a specific activity of approximately.
Avonex is a disease modifying drug dmd for relapsing remitting ms. 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. Just fill out this form and bring it to your health care professional. Getting your prescription the avonex start form is your key to. If you have completed a printed start form, fax the start form to 18554743067. 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. Please complete the following questions and then fax this form to the toll free number listed below.
Sep 11, 2019 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. Apr 09, 2020 avonex is a form of a protein called beta interferon that occurs naturally in the body. Copaxone is contraindicated in patients with known hypersensitivity to glatiramer acetate or mannitol. 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 interferon beta1a is a 166 amino acid glycoprotein with a predicted molecular. Avonex prior authorization request form member information. 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 and rebif are the meds,difference is avonex is in the muscle and once a week,rebif is under the skin. Avonex interferon beta1a rch powder for injection and solution for injection.
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. By giving us your email address, you can stay up to date on. Before your injection, avonex psavonex pen should be taken out of the refrigerator and allowed to warm to room temperature over 30 minutes. Do not use external heat sources, such as hot water, to warm avonex psavonex pen. Avonex helps most people with ms but it may have unwanted effects in a few people. Avonex express scripts prior authorization phone 18444248886 fax 18772515896. Interferon beta1a also interferon beta 1alpha is a cytokine in the interferon family used to treat multiple sclerosis ms. The first avonex injection should be performed under the supervision of an appropriately qualified health care professional.
Prepare an injection only when you are ready to give it. It is produced by mammalian cells, while interferon beta1b is produced in modified e. Interferon beta1a is a form of a protein that occurs naturally in the body. Tecfidera dimethyl fumarate prescribing information and. Instructions for healthcare providers tecus0298 v9 0120. Avonex interferon beta1a medication precertification.
Avonex is a prescription medicine used to treat relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease. Only gilenya combines proven efficacy to cut multiple sclerosis ms relapses in half vs avonex, in a onceaday pill. 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. 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. Avonex and rebif are the brand names of the injectable medicine interferon beta1a, which is used to treat symptoms of relapsingremitting multiple sclerosis rrms. To start your part d coverage determination request, you or your representative or your doctor or other prescriber should contact express scripts, inc esi.
Copy both sides of the patients medical insurance card and pharmacy benefit card, if available. Upon receipt of the completed form, prescription benefit coverage will be determined based on the benefit plans rules. 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. Gilenya patient assistance start gilenya fingolimod. The powder form of this medicine must be mixed with a liquid diluent before using it. Do not use if the medicine has changed colors or has particles in it. Forms are updated frequently and may be barcoded member information required provider information required member name. Simply fill out your portion of the form, and your health care professional will handle the rest. Serious side effects may happen right after or within. What is avonex goodrx avonex generic interferon beta 1a avonex clinical pharmacology avonex pen at rs 10934 unit id. 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.
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. The characteristics of the clinical course of ms may be classified into four categories. Copaxone glatiramer acetate injection for relapsing 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. Dispense as written brand exchange permissible date. Interferon beta1a is a 166 amino acid glycoprotein with a predicted molecular weight of approximately 22,500 daltons. Avonex interferon beta1a medication precertification request. Give your patient the instructions for patients and patient consent information pages. I attest the information provided is true and accurate to the best of my knowledge. Avonex interferon beta1a drug medicine information.
A start form must be completed and faxed to the abovems program. Avonex is injected into a muscle, usually once weekly at bedtime, on the same day each week such as every monday. The avostartgrip is used for giving the week 1, 2, and 3. Copaxone copay solutions program rules for copaxone glatiramer acetate injection 20 mgpatient eligibility, terms and conditions. To start your part d coverage determination request, you or your representative or your doctor or. Plegridy is a prescription medicine used to treat relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease. 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. 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.
All avonex dosage forms are singleuse injection of reconstituted solution. In some cases, the medical and pharmacy cards may be the same. Page 2 of 2 section b physician signature physician signature date fax completed form to. Your medical treatment, payments, insurance enrollment, or eligibility for insurance benefits do not depend on your signing this form. Avonex interferon beta 1a medication precertification request. Patient authorization and betaplus enrollment form for. It reduces the number of relapses by about one third 30%, compared to taking placebo. You may call esi at 18444248886, 24 hours a day, 7 days a week, tty users. Nonformulary interferon beta1a avonex will be covered on the prescription drug benefit for 12 months when the following criteria are met. Betaseron is the first fdaapproved medicine to reduce disease activity in patients. Avonex psavonex pen should be stored in a refrigerator at 2c to 8c. Avonex is for the treatment of relapsing forms of multiple sclerosis ms. If youre thinking about taking gilenya, this section was made just for. Some claims have been made that interferons produce.
Avostartgrip titration kit instructions for use avonex. Prior authorization prescriber fax form copaxone coverage determination this fax machine is located in a secure location as required by hipaa regulations. 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. Do not use avonex or diluent past the expiration date. 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. Patient name address city state zip home phone cell phone preferred time to call sex. Criteriabased consultation prescribing program criteria.
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