Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Natalizumab (Tysabri) may be considered medically necessary for EITHER of the following conditions:
Multiple Sclerosis (MS)
Avonex (interferon beta-1a)
Betaseron (interferon beta-1b)
Plegridy (peginterferon beta-1a)
Rebif (interferon beta-1a)
Tecfidera (dimethyl fumarate)
Crohn’s Disease (CD)
Natalizumab (Tysabri) is considered experimental/investigational and, therefore, non-covered for all other indications. Scientific evidence does not support its use for any other indication.
Natalizumab (Tysabri) is not indicated for the treatment of chronic progressive multiple sclerosis.
Natalizumab (Tysabri) is available only through a special restricted distribution program called the TOUCH Prescribing Program. Natalizumab (Tysabri) must be administered only to individuals with MS or individuals with CD registered in the MS TOUCH Prescribing or CD TOUCH Prescribing Program, respectively.
Note: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.