Description: Natalizumab injection
Unit: 1 mg
Pay quarter: Q3 2023
Dosage and Frequency
Crohn's Disease (CD)
• 300mg IV every 4 weeks
Calculate drug reimbursement
(ASP: $7,458.90, Margin: $447.53)
# Units to bill:300
Prior auth criteria for Tysabri may include but is not limited to:
1) Patient is 18 years of age or older.
2) Patient has a confirmed diagnosis of relapsing remitting multiple sclerosis (RRMS) as defined by McDonald criteria.
3) Patient has had an inadequate response to, or is unable to tolerate, an alternate disease-modifying therapy for RRMS.
4) Patient does not have progressive multifocal leukoencephalopathy (PML).
5) Patient does not have any active infection or history of recurrent infection.
6) Patient is negative for anti-JC virus antibody.
7) Patient is not pregnant or breastfeeding.
8) Patient has not had a positive test result for hepatitis B virus surface antigen (HBsAg) or human immunodeficiency virus (HIV).
9) Patient has not had a demyelinating event within one month prior to initiation of Tysabri therapy.
10) Patient is enrolled in and compliant with the Tysabri Outcome Survey (TOS) and has agreed to comply with all of its requirements.
Insurance prior auth guidelines: