Category Filter
- Advanced Imaging
- Behavioral Health
- Chronic Condition Management
- Genetic Testing
- Hemophilia Drugs
- Medical Oncology Regimen Program
- Medical Policies
- Pre-Service Review (Precertification/Predetermination)
- Provider-Administered Drug Policies
- Radiation Therapy
- Self-Administered Drug Policies
- Transgender Services
Asset Publisher
Multiple Sclerosis Agents Step Therapy with Quantity Limit Program Summary
Policy Number: PH-1057
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
10-01-2024 |
|
FDA LABELED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Aubagio® (teriflunomide)* Tablet |
Treatment of patients with relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
*generic equivalent available |
1 |
Avonex® (interferon β-1a) Injection for intramuscular use |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
2 |
Bafiertam® (monomethyl fumarate) Delayed-release capsule |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
3 |
Betaseron® (interferon β-1b) Injection for subcutaneous use |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
4 |
Copaxone® (glatiramer acetate)* Injection for subcutaneous use |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
*generic equivalent available |
5 |
Extavia® (interferon β-1b) Injection for subcutaneous use |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
6 |
Gilenya® (fingolimod)* Capsule |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in patients 10 years of age and older |
*generic equivalent available |
7 |
Glatopa® (glatiramer acetate) Injection for subcutaneous use |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
8 |
Kesimpta® (ofatumumab) Injection for subcutaneous use |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
9 |
Mavenclad® (cladribine) Tablet |
Treatment of relapsing forms of multiple sclerosis (MS), to include relapsing-remitting disease and active secondary progressive disease in adults Because of its safety profile, use of Mavenclad is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternative drug indicated for the treatment of MS Limitation of Use: |
|
10 |
Mayzent® (siponimod) Tablet |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
11 |
Plegridy® (peginterferon β-1a) Injection for subcutaneous use or intramuscular use |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
12 |
Ponvory® (ponesimod) Tablet |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
27 |
Rebif® (interferon β-1b) Injection for subcutaneous use |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
13 |
Tascenso® (fingolimod) Oral disintegrating tablet |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in patients 10 years of age and older |
|
29 |
Tecfidera® (dimethyl fumarate)* Capsule |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
*generic equivalent available |
14 |
Vumerity® (diroximel fumarate) Delayed-release capsule |
Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults |
|
15 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
Multiple sclerosis |
Multiple sclerosis (MS) is a disorder of the central nervous system (CNS) characterized by demyelization, inflammation, and degenerative changes. Most people with MS experience relapses and remissions of neurological symptoms, particularly early in the disease, and clinical events are usually associated with areas of CNS inflammation. Gradual worsening or progression, with or without subsequent acute attacks of inflammation or radiological activity, may take place early, but usually becomes more prominent over time. While traditionally viewed as a disease solely of CNS white matter, more advanced imaging techniques have demonstrated significant early and ongoing CNS gray matter damage as well.(16) Those diagnosed with MS may have many fluctuating and disabling symptoms (including, but not limited to, fatigue, pain, bladder and bowel issues, sexual dysfunction, movement and coordination problems, visual disturbances, and cognition and emotional changes.(30) There are currently four major types of MS: clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), primary progressive MS (PPMS), and secondary progressive MS (SPMS).(23) |
|||||||||||||||||||||||||||||||||||||||||
Relapsing remitting multiple sclerosis (RRMS) |
RRMS is characterized by clearly defined attacks (relapses) of new or increasing neurologic symptoms. These relapses are followed by periods of partial or complete recovery. There is no or minimal disease progression during the periods between disease relapses, though individual relapses may result in severe residual disability. The course of MS varies, however, about 85-90% of individuals with MS demonstrate a relapsing pattern at onset, which transitions over time in the majority of untreated patients to a pattern of progressive worsening with few or no relapses or MRI activity.(23) |
|||||||||||||||||||||||||||||||||||||||||
Secondary progressive multiple sclerosis (SPMS) |
SPMS begins as RRMS, but over time the disease enters a stage of steady deterioration in function, unrelated to acute attacks. Most people with RRMS will transition to SPMS. In SPMS there is no progressive worsening of symptoms over time with no definite periods of remission.(23) |
|||||||||||||||||||||||||||||||||||||||||
2017 McDonald Criteria for the diagnosis of Multiple Sclerosis: |
Diagnostic criteria for multiple sclerosis combining clinical, imaging, and laboratory evidence have evolved over time. The increasing incorporation of paraclinical assessments, especially imaging, to supplement clinical findings has allowed earlier, more sensitive, and more specific diagnosis.(21,22) The diagnosis of MS requires elimination of more likely diagnoses and demonstration of dissemination of lesions in the CNS in space and time.(21) Misdiagnosis of multiple sclerosis remains an issue in clinical practice, and several factors that potentially increase this risk have been identified. Multiple sclerosis has heterogeneous clinical and imaging manifestations, which differ between patients over time. There is no single pathognomonic clinical feature or diagnostic test; diagnosis of multiple sclerosis relies on the integration of clinical, imaging, and laboratory findings. MRI abnormalities associated with other diseases and non-specific MRI findings, which are common in the general population, can be mistaken for multiple sclerosis. The increasingly strong focus on timely diagnosis to alleviate uncertainty for patients and allow initiation of disease-modifying therapies might also increase the risk of misdiagnosis.(21) With increasing availability and use of MRI, incidental T2 hyperintensities on brain imaging are common, the subset of individuals with MRI findings that are strongly suggestive of multiple sclerosis lesions but with no neurological manifestations or other clear-cut explanation are said to have radiologically isolated syndrome. There is no consensus on whether patients with radiologically isolated syndrome will develop MS. Some practitioners argue that these patients have a high likelihood of developing MS while others argue that up to two-thirds of these patients will not receive a diagnosis of MS in 5 years. A consensus panel decided to require clinical manifestations to make the diagnosis of MS (2017 McDonald Criteria for the diagnosis of Multiple Sclerosis).(21) The 2017 McDonald criteria to diagnose MS is shown in the chart below.(21,22)
*Dissemination in space is defined as one or more T2-hyperintense lesions that are characteristic of multiple sclerosis in 2 or more of four areas of the CNS (periventricular, cortical or juxtacortical, and infratentorial brain regions, and the spinal cord) demonstrated by an additional clinical attack implicating a different CNS site or by MRI.(21) **Dissemination in time is defined as simultaneous presence of gadolinium-enhancing and non-enhancing lesions at any time or by a new T2-hyperintense or gadolinium-enhancing lesion on follow-up MRI, with reference to a baseline scan, irrespective of the timing of the baseline MRI. The presence of CSF-specific oligoclonal bands does not demonstrate dissemination in time per se but can substitute for the requirement for demonstration of this measure.(21) |
|||||||||||||||||||||||||||||||||||||||||
Treatment of MS |
Both the Multiple Sclerosis Coalition and the American Academy of Neurology recommend initiating treatment with a DMA FDA approved for the patient’s phenotype as soon as possible following the diagnosis of multiple sclerosis. There are several DMAs with at least 10 mechanisms of action available to people with MS. The factors affecting choice of therapy at any point in the disease course are complex and most appropriately analyzed and addressed through a shared decision-making process between the individual and the treating clinician.(16,19) The Multiple Sclerosis Coalition recommends that clinicians should consider prescribing a high efficacy medication such as alemtuzumab, cladribine, fingolimod, natalizumab or ocrelizumab for newly diagnosed individuals with highly active MS. Clinicians should also consider prescribing a high efficacy medication for individuals who have breakthrough activity on another DMA regardless of the number of previously used agents.(16) The American Academy of Neurology has recommended alemtuzumab, fingolimod, and natalizumab as options for patients with MS with highly active MS. There lacks a consensus for what constitutes as highly active MS, however.(19) The National Institute for Health and Care Excellence (NICE) defines rapidly evolving severe RRMS as two or more disabling relapses in 1 year, and one or more gadolinium-enhancing lesions on brain MRI or a significant increase in T2 lesion load compared with a previous MRI.(31) Lack of response to DMAs is hard to define, as most patients with MS are not free of all disease activity. Relapses or new MRI detected lesions may develop after initiation of a DMA and before the treatment becomes effective for patients. When determining efficacy, sufficient time for the DMA therapy to take full effect and patient adherence are important considerations. Evidence of one or more relapses, 2 or more unequivocally new MRI-detected lesions, or increased disability on examination while being treated with a DMA for a 1 year period suggests a sub-optimal response, an alternative regimen (e.g., different mechanism of action) should be considered to optimize therapeutic benefit.(18) A National MS Society consensus statement recommends changing from one disease modifying therapy to another only for medically appropriate reasons (e.g., lack of efficacy, adverse effects, or if better treatments options become available).(16) Existing MS therapies are partly effective in halting ongoing inflammatory tissue damage and clinical progression. MS pathogenesis is complex and probably heterogeneous among patient, suggesting that combination therapy strategies that target a range of disease mechanisms might be more effective than medications used as monotherapy. Although preliminary studies have provided favorable results, however, several subsequent large, randomized, controlled trials have had negative of conflicting results. There also may be more adverse reactions associated with combination therapies due to the additive effect.(24) In 2020 a Canadian MS working group published recommendations on optimal therapy in relapsing forms of MS. This group notes that there are few studies that have directly compared injectable and oral DMTs. A recent network meta-analysis suggested that pegylated interferon-β-1a and dimethyl fumarate have superior efficacy to other base therapies, there are insufficient data to demonstrate that one base injectable or oral DMT is superior to another. As a result, the choice of initial treatment will need to be individualized according to disease activity, severity, and comorbidities.(25) In addition to base therapies, the working group considers 5 DMTs to be of higher efficacy which although can be used as initial therapy, they are generally reserved for patients with a poor response or tolerability with a base therapy. Patients presenting with high disease activity or aggressive/rapidly evolving MS at onset could be considered to initiate therapy with one of these more effective therapies, but the most common treatment initiation is to start on a base therapy with the view of switching within 6-12 months. The 5 agents considered to be of higher efficacy are:(25)
The MS working group discussed the criteria for switching therapies in RRMS and recommends a change in DMT is indicated for patients who meet any of the Major criteria below:(25)
The workgroup does note that on-treatment relapses should only be performed once the drug has achieved a full clinical effect (typically 2-6 months after drug initiation). Relapses that occur before the maximal efficacy of the drug has been reached should be given less weight, but major criteria should take precedence regardless of timing.(25) For patients with SPMS the workgroup states that is generally advised to continue with the current DMT after onset of SPMS since many patients will have ongoing inflammatory disease and subclinical disease activity may worsen if treatment is withdrawn. A change in treatment may be warranted in patients with active SPMS who continue to have relapses or new MRI lesions, with the caveat that there is insufficient evidence to identify criteria for a suboptimal response in patients with SPMS.(25) For patients with primary progressive MS clinicians should offer ocrelizumab to patients with active disease provided the benefits outweigh the risks. Caution is recommended when considering treatment for PPMS subgroups that are less likely to benefit from treatment, such as older patients, those with long-standing stable disease, and/or significant neurological deficits, since the limited benefits may not justify the risk associated with treatment. Rituximab may be considered as an alternative therapy for PPMS in regions that permit off-label use in MS due to cost or other considerations.(25) The Institute for Clinical and Economic Review (ICER) evaluated a new IV treatment, ublituximab against current FDA and accepted use DMT for adults with RRMS. Only in the case of ublituximab vs placebo/no DMT is ublituximab superior rated. The ratings are noted below.(17) Adults with RRMS
A: Superior - High certainty of a substantial (moderate-large) net health benefit ICER does note that payors should consider the following:(17)
|
|||||||||||||||||||||||||||||||||||||||||
Safety |
|
REFERENCES
Number |
Reference |
1 |
Aubagio prescribing information. Genzyme Corporation. December 2022. |
2 |
Avonex prescribing information. Biogen, Inc. July 2023. |
3 |
Bafiertam prescribing information. Banner Life Sciences LLC. January 2023. |
4 |
Betaseron prescribing information. Bayer HealthCare Pharmaceuticals, Inc. July 2023. |
5 |
Copaxone prescribing information. Teva Neuroscience, Inc. February 2023. |
6 |
Extavia prescribing information. Novartis Pharmaceuticals Corporation. July 2023. |
7 |
Gilenya prescribing information. Novartis Pharmaceuticals Corporation. August 2023. |
8 |
Glatopa prescribing information. Sandoz Inc. March 2023. |
9 |
Kesimpta prescribing information. Novartis Pharmaceuticals Corporation. September 2022. |
10 |
Mavenclad prescribing information. EMD Serono, Inc. September 2022. |
11 |
Mayzent prescribing information. Novartis Pharmaceuticals Corporation. August 2023. |
12 |
Plegridy prescribing information. Biogen, Inc. July 2023. |
13 |
Rebif prescribing information. EMD Serono, Inc. July 2023. |
14 |
Tecfidera prescribing information. Biogen, Inc. February 2023. |
15 |
Vumerity prescribing information. Biogen Inc. February 2023. |
16 |
Multiple Sclerosis Coalition. The Use of Disease Modifying Therapies in Multiple Sclerosis: Principals and Current Evidence. Updated June 2019. National Multiple Sclerosis Society. Available at: https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/DMT_Consensus_MS_Coalition.pdf. |
17 |
Institute for Clinical and Economic Review (ICER). Oral and Monoclonal Antibody Treatments for Relapsing Forms of Multiple Sclerosis: Effectiveness and Value. February 21, 2023. |
18 |
Rae-Grant, Alexander, MD, et al. Practice Guideline Recommendations Summary: Disease-Modifying Therapies for Adults with Multiple Sclerosis. Neurology. 2018;90:777-788. |
19 |
Corboy, John R, MD, et al. Comment on 2018 American Academy of Neurology Guidelines on Disease-Modifying Therapies in MS. Neurology. 2018;90:1106-1112. |
20 |
Reference no longer used |
21 |
Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis:2017 revisions of the McDonald criteria. Lancet Neurol 2018; 17:162-73. |
22 |
National Multiple Sclerosis Society 2017 McDonald MS Diagnostic Criteria. Available at: https://www.nationalmssociety.org/For-Professionals/Clinical-Care/Diagnosing-MS/Diagnosing-Criteria. |
23 |
MS international federation. Types of MS. Last updated 12th March 2022. Accessed at Types of MS | Multiple Sclerosis (msif.org) |
24 |
Conway D, Cohen JA. Combination therapy in multiple sclerosis. Lancet Neurol 2010 Mar;9(3):299-308. |
25 |
Freedman MS, Devonshire V, Duquette P, et al. Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations. The Can J Neurol Sci. 2020;47:437-455. |
26 |
Reference no longer used |
27 |
Ponvory prescribing information. Janssen Pharmaceuticals, Inc. April 2021. |
28 |
Kitzler HH, Wahl H, Eisele JC, et al. Multi-component relaxation in clinically isolated syndrome; Lesion myelination may predict multiple sclerosis conversion. NeuroImage:Clinical 20 (2018)61-70. |
29 |
Tascenso prescribing information. Handa Neuroscience, LLC. December 2022. |
30 |
MS international federation. About MS - Symptoms. Accessed at MS Symptoms | Multiple Sclerosis (msif.org). |
31 |
National Institute for Health and Care Excellence. NICE Guidance - Conditions and diseases - Neurological conditions - Multiple sclerosis. Ofatumumab for treating relapsing multiple sclerosis. Technology appraisal guidance [TA699] Published:19 May 2021. Accessed at 3 Committee discussion | Ofatumumab for treating relapsing multiple sclerosis | Guidance | NICE. |
POLICY AGENT SUMMARY STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
|
||||||
|
dimethyl fumarate capsule delayed release ; dimethyl fumarate capsule dr starter pack |
120 & 240 MG ; 120 MG ; 240 MG |
Y |
O ; Y |
|
1. Preferred |
|
fingolimod hcl cap |
0.25 MG ; 0.5 MG |
Y |
N ; O ; Y |
|
1. Preferred |
|
teriflunomide tab |
14 MG ; 7 MG |
Y |
O ; Y |
|
1. Preferred |
Avonex ; Avonex pen ; Rebif ; Rebif rebidose ; Rebif rebidose titration ; Rebif titration pack |
interferon beta- |
22 MCG/0.5ML ; 30 MCG/0.5ML ; 44 MCG/0.5ML ; 6X8.8 & 6X22 MCG |
M ; N ; O ; Y |
N |
|
1. Preferred |
Betaseron |
interferon beta- |
0.3 MG |
M ; N ; O ; Y |
N |
|
1. Preferred |
Glatopa |
glatiramer acetate soln prefilled syringe |
20 MG/ML ; 40 MG/ML |
Y |
O ; Y |
|
1. Preferred |
Kesimpta |
ofatumumab soln auto-injector |
20 MG/0.4ML |
M ; N ; O ; Y |
N |
|
1. Preferred |
Mavenclad |
cladribine tab therapy pack |
10 MG |
M ; N ; O ; Y |
N |
|
1. Preferred |
Mayzent ; Mayzent starter pack |
siponimod fumarate tab |
0.25 MG ; 1 MG ; 2 MG |
M ; N ; O ; Y |
N |
|
1. Preferred |
Plegridy ; Plegridy starter pack |
peginterferon beta- |
125 MCG/0.5ML ; 63 & 94 MCG/0.5ML |
M ; N ; O ; Y |
N |
|
1. Preferred |
Vumerity |
diroximel fumarate capsule delayed release |
231 MG |
M ; N ; O ; Y |
N |
|
1. Preferred |
Aubagio |
teriflunomide tab |
14 MG ; 7 MG |
M ; N ; O |
O ; Y |
|
2. Non-Preferred |
Bafiertam |
monomethyl fumarate capsule delayed release |
95 MG |
M ; N ; O ; Y |
N |
|
2. Non-Preferred |
Copaxone |
glatiramer acetate soln prefilled syringe |
20 MG/ML ; 40 MG/ML |
M ; N ; O |
O ; Y |
|
2. Non-Preferred |
Extavia |
interferon beta- |
0.3 MG |
M ; N ; O ; Y |
N |
|
2. Non-Preferred |
Gilenya |
fingolimod hcl cap |
0.25 MG ; 0.5 MG |
M ; N ; O |
N ; O ; Y |
|
2. Non-Preferred |
Ponvory ; Ponvory 14-day starter pa |
ponesimod tab ; ponesimod tab starter pack |
2-3-4-5-6-7-8-9 & 10 MG ; 20 MG |
M ; N ; O ; Y |
N |
|
2. Non-Preferred |
Tascenso odt |
fingolimod lauryl sulfate tablet disintegrating |
0.25 MG ; 0.5 MG |
M ; N ; O ; Y |
N |
|
2. Non-Preferred |
Tecfidera ; Tecfidera starter pack |
dimethyl fumarate capsule delayed release ; dimethyl fumarate capsule dr starter pack |
120 & 240 MG ; 120 MG ; 240 MG |
M ; N ; O |
O ; Y |
|
2. Non-Preferred |
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
Aubagio |
teriflunomide tab |
14 MG ; 7 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Avonex |
interferon beta- |
30 MCG/0.5ML |
4 |
Syringes |
28 |
DAYS |
|
|
|
Avonex pen |
interferon beta- |
30 MCG/0.5ML |
4 |
Pens |
28 |
DAYS |
|
|
|
Bafiertam |
monomethyl fumarate capsule delayed release |
95 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Betaseron |
interferon beta- |
0.3 MG |
14 |
Vials |
28 |
DAYS |
|
|
50419052401 ; 50419052435; |
Copaxone |
glatiramer acetate soln prefilled syringe |
20 MG/ML |
30 |
Syringes |
30 |
DAYS |
|
|
68546031730 |
Copaxone ; Glatopa |
glatiramer acetate soln prefilled syringe |
20 MG/ML |
30 |
Syringes |
30 |
DAYS |
|
|
00781323434 ; 00781323471; |
Copaxone ; Glatopa |
glatiramer acetate soln prefilled syringe |
40 MG/ML |
12 |
Syringes |
28 |
DAYS |
|
|
00781325071 ; 00781325089;63629881601 |
Copaxone ; Glatopa |
Glatiramer Acetate Soln Prefilled Syringe 20 MG/ML |
20 MG/ML |
30 |
Syringes |
30 |
DAYS |
|
|
|
Copaxone ; Glatopa |
Glatiramer Acetate Soln Prefilled Syringe 40 MG/ML |
40 MG/ML |
12 |
Syringes |
28 |
DAYS |
|
|
|
Copaxone ; Glatopa |
Glatiramer Acetate Soln Prefilled Syringe 40 MG/ML |
40 MG/ML |
12 |
Syringes |
28 |
DAYS |
|
|
|
Extavia |
interferon beta- |
0.3 MG |
15 |
Vials |
30 |
DAYS |
|
|
00078056912 ; 00078056961 ; 00078056999; |
Gilenya |
fingolimod hcl cap |
0.25 MG ; 0.5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Kesimpta |
ofatumumab soln auto-injector |
20 MG/0.4ML |
1 |
Pen |
28 |
DAYS |
|
|
|
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (10 Tabs) |
10 MG |
20 |
Tablets |
301 |
DAYS |
|
|
|
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (4 Tabs) |
10 MG |
8 |
Tablets |
301 |
DAYS |
|
|
|
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (5 Tabs) |
10 MG |
10 |
Tablets |
301 |
DAYS |
|
|
|
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (6 Tabs) |
10 MG |
12 |
Tablets |
301 |
DAYS |
|
|
|
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (7 Tabs) |
10 MG |
14 |
Tablets |
301 |
DAYS |
|
|
|
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (8 Tabs) |
10 MG |
8 |
Tablets |
301 |
DAYS |
|
|
|
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (9 Tabs) |
10 MG |
9 |
Tablets |
301 |
DAYS |
|
|
|
Mayzent |
Siponimod Fumarate Tab |
1 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Mayzent |
Siponimod Fumarate Tab 0.25 MG (Base Equiv) |
0.25 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Mayzent |
Siponimod Fumarate Tab 2 MG (Base Equiv) |
2 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Mayzent starter pack |
Siponimod Fumarate Tab |
0.25 MG |
1 |
Kit |
180 |
DAYS |
|
|
|
Mayzent starter pack |
Siponimod Fumarate Tab 0.25 MG (12) Starter Pack |
0.25 MG |
12 |
Tablets |
180 |
DAYS |
|
|
|
Plegridy |
Peginterferon Beta- |
125 MCG/0.5ML |
2 |
Syringes |
28 |
DAYS |
|
|
|
Plegridy |
Peginterferon Beta-1a Soln Pen-injector 125 MCG/0.5ML |
125 MCG/0.5ML |
2 |
Pens |
28 |
DAYS |
|
|
|
Plegridy |
Peginterferon Beta-1a Soln Prefilled Syringe 125 MCG/0.5ML |
125 MCG/0.5ML |
2 |
Syringes |
28 |
DAYS |
|
|
|
Plegridy starter pack |
Peginterferon Beta-1a Soln Pen-inj 63 & 94 MCG/0.5ML Pack |
63 & 94 MCG/0.5ML |
1 |
Kit |
180 |
DAYS |
|
|
|
Plegridy starter pack |
Peginterferon Beta-1a Soln Pref Syr 63 & 94 MCG/0.5ML Pack |
63 & 94 MCG/0.5ML |
1 |
Kit |
180 |
DAYS |
|
|
|
Ponvory |
Ponesimod Tab |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Ponvory 14-day starter pa |
Ponesimod Tab Starter Pack |
2-3-4-5-6-7-8-9 & 10 MG |
14 |
Tablets |
180 |
DAYS |
|
|
|
Rebif ; Rebif titration pack |
interferon beta- |
22 MCG/0.5ML ; 44 MCG/0.5ML ; 6X8.8 & 6X22 MCG |
12 |
Syringes |
28 |
DAYS |
|
|
|
Rebif rebidose ; Rebif rebidose titration |
interferon beta- |
22 MCG/0.5ML ; 44 MCG/0.5ML ; 6X8.8 & 6X22 MCG |
12 |
Syringes |
28 |
DAYS |
|
|
|
Rebif rebidose titration |
Interferon Beta-1a Auto-inj 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML |
6X8.8 & 6X22 MCG |
1 |
Kit |
180 |
DAYS |
|
|
|
Rebif titration pack |
Interferon Beta-1a Pref Syr 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML |
6X8.8 & 6X22 MCG |
1 |
Kit |
180 |
DAYS |
|
|
|
Tascenso odt |
fingolimod lauryl sulfate tablet disintegrating |
0.25 MG ; 0.5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Tecfidera |
dimethyl fumarate capsule delayed release |
120 MG |
14 |
Capsules |
180 |
DAYS |
|
|
64406000501 |
Tecfidera |
dimethyl fumarate capsule delayed release |
240 MG |
60 |
Capsules |
30 |
DAYS |
|
|
64406000602 |
Tecfidera |
Dimethyl Fumarate Capsule Delayed Release 120 MG |
120 MG |
14 |
Capsules |
180 |
DAYS |
|
|
|
Tecfidera |
Dimethyl Fumarate Capsule Delayed Release 240 MG |
240 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Tecfidera starter pack |
dimethyl fumarate capsule dr starter pack |
120 & 240 MG |
60 |
Capsules |
180 |
DAYS |
|
|
|
Vumerity |
diroximel fumarate capsule delayed release |
231 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
dimethyl fumarate capsule delayed release ; dimethyl fumarate capsule dr starter pack |
120 & 240 MG ; 120 MG ; 240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
fingolimod hcl cap |
0.25 MG ; 0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
teriflunomide tab |
14 MG ; 7 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Avonex ; Avonex pen ; Rebif ; Rebif rebidose ; Rebif rebidose titration ; Rebif titration pack |
interferon beta- |
22 MCG/0.5ML ; 30 MCG/0.5ML ; 44 MCG/0.5ML ; 6X8.8 & 6X22 MCG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Betaseron |
interferon beta- |
0.3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Glatopa |
glatiramer acetate soln prefilled syringe |
20 MG/ML ; 40 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kesimpta |
ofatumumab soln auto-injector |
20 MG/0.4ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mavenclad |
cladribine tab therapy pack |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mayzent ; Mayzent starter pack |
siponimod fumarate tab |
0.25 MG ; 1 MG ; 2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Plegridy ; Plegridy starter pack |
peginterferon beta- |
125 MCG/0.5ML ; 63 & 94 MCG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vumerity |
diroximel fumarate capsule delayed release |
231 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Aubagio |
teriflunomide tab |
14 MG ; 7 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Bafiertam |
monomethyl fumarate capsule delayed release |
95 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copaxone |
glatiramer acetate soln prefilled syringe |
20 MG/ML ; 40 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Extavia |
interferon beta- |
0.3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gilenya |
fingolimod hcl cap |
0.25 MG ; 0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ponvory ; Ponvory 14-day starter pa |
ponesimod tab ; ponesimod tab starter pack |
2-3-4-5-6-7-8-9 & 10 MG ; 20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tascenso odt |
fingolimod lauryl sulfate tablet disintegrating |
0.25 MG ; 0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tecfidera ; Tecfidera starter pack |
dimethyl fumarate capsule delayed release ; dimethyl fumarate capsule dr starter pack |
120 & 240 MG ; 120 MG ; 240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
Aubagio |
teriflunomide tab |
14 MG ; 7 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Avonex |
interferon beta- |
30 MCG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Avonex pen |
interferon beta- |
30 MCG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Bafiertam |
monomethyl fumarate capsule delayed release |
95 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Betaseron |
interferon beta- |
0.3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copaxone |
glatiramer acetate soln prefilled syringe |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copaxone ; Glatopa |
glatiramer acetate soln prefilled syringe |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copaxone ; Glatopa |
glatiramer acetate soln prefilled syringe |
40 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copaxone ; Glatopa |
Glatiramer Acetate Soln Prefilled Syringe 20 MG/ML |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copaxone ; Glatopa |
Glatiramer Acetate Soln Prefilled Syringe 40 MG/ML |
40 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copaxone ; Glatopa |
Glatiramer Acetate Soln Prefilled Syringe 40 MG/ML |
40 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Extavia |
interferon beta- |
0.3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gilenya |
fingolimod hcl cap |
0.25 MG ; 0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kesimpta |
ofatumumab soln auto-injector |
20 MG/0.4ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (10 Tabs) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (4 Tabs) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (5 Tabs) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (6 Tabs) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (7 Tabs) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (8 Tabs) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mavenclad |
Cladribine Tab Therapy Pack 10 MG (9 Tabs) |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mayzent |
Siponimod Fumarate Tab |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mayzent |
Siponimod Fumarate Tab 0.25 MG (Base Equiv) |
0.25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mayzent |
Siponimod Fumarate Tab 2 MG (Base Equiv) |
2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mayzent starter pack |
Siponimod Fumarate Tab |
0.25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mayzent starter pack |
Siponimod Fumarate Tab 0.25 MG (12) Starter Pack |
0.25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Plegridy |
Peginterferon Beta- |
125 MCG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Plegridy |
Peginterferon Beta-1a Soln Pen-injector 125 MCG/0.5ML |
125 MCG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Plegridy |
Peginterferon Beta-1a Soln Prefilled Syringe 125 MCG/0.5ML |
125 MCG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Plegridy starter pack |
Peginterferon Beta-1a Soln Pen-inj 63 & 94 MCG/0.5ML Pack |
63 & 94 MCG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Plegridy starter pack |
Peginterferon Beta-1a Soln Pref Syr 63 & 94 MCG/0.5ML Pack |
63 & 94 MCG/0.5ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ponvory |
Ponesimod Tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ponvory 14-day starter pa |
Ponesimod Tab Starter Pack |
2-3-4-5-6-7-8-9 & 10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rebif ; Rebif titration pack |
interferon beta- |
22 MCG/0.5ML ; 44 MCG/0.5ML ; 6X8.8 & 6X22 MCG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rebif rebidose ; Rebif rebidose titration |
interferon beta- |
22 MCG/0.5ML ; 44 MCG/0.5ML ; 6X8.8 & 6X22 MCG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rebif rebidose titration |
Interferon Beta-1a Auto-inj 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML |
6X8.8 & 6X22 MCG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rebif titration pack |
Interferon Beta-1a Pref Syr 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML |
6X8.8 & 6X22 MCG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tascenso odt |
fingolimod lauryl sulfate tablet disintegrating |
0.25 MG ; 0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tecfidera |
dimethyl fumarate capsule delayed release |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tecfidera |
dimethyl fumarate capsule delayed release |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tecfidera |
Dimethyl Fumarate Capsule Delayed Release 120 MG |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tecfidera |
Dimethyl Fumarate Capsule Delayed Release 240 MG |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tecfidera starter pack |
dimethyl fumarate capsule dr starter pack |
120 & 240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vumerity |
diroximel fumarate capsule delayed release |
231 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
STEP THERAPY CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
||||||||||||||||
|
*subject to duplicate therapy check only Target Agent(s) will be approved when ALL of the following are met:
Length of Approval: 12 months. NOTE: For agents requiring a starter dose for initial use, the starter dose can be approved for the FDA labeled starting dose and the maintenance dose can be approved for the remainder of 12 months. NOTE: If Quantity Limit applies, please refer to Quantity Limit criteria. *Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required. |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
QL with ST |
Quantity Limit for Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months NOTE: For agents requiring a starter dose for initial use, the starter dose can be approved for the FDA labeled starting dose and the maintenance dose can be approved for the remainder of 12 months
|
CLASS AGENTS
Class |
Class Drug Agents |
Class Ia antiarrhythmics |
|
Class Ia antiarrhythmics |
NORPACE*Disopyramide Phosphate Cap |
Class Ia antiarrhythmics |
Pronestyl (procainamide) |
Class Ia antiarrhythmics |
quinidine |
Class III antiarrhythmics |
|
Class III antiarrhythmics |
BETAPACE*Sotalol HCl Tab |
Class III antiarrhythmics |
Cordarone, Pacerone (amiodarone) |
Class III antiarrhythmics |
CORVERT*Ibutilide Fumarate Inj |
Class III antiarrhythmics |
MULTAQ*Dronedarone HCl Tab |
Class III antiarrhythmics |
TIKOSYN*Dofetilide Cap |
MS Disease Modifying Agents drug class: CD20 monoclonal antibody |
|
MS Disease Modifying Agents drug class: CD20 monoclonal antibody |
BRIUMVI*ublituximab-xiiy soln for iv infusion |
MS Disease Modifying Agents drug class: CD20 monoclonal antibody |
KESIMPTA*Ofatumumab Soln Auto-Injector |
MS Disease Modifying Agents drug class: CD20 monoclonal antibody |
OCREVUS*Ocrelizumab Soln For IV Infusion |
MS Disease Modifying Agents drug class: CD52 monoclonal antibody |
|
MS Disease Modifying Agents drug class: CD52 monoclonal antibody |
LEMTRADA*Alemtuzumab IV Inj |
MS Disease Modifying Agents drug class: Fumarates |
|
MS Disease Modifying Agents drug class: Fumarates |
BAFIERTAM*Monomethyl Fumarate Capsule Delayed Release |
MS Disease Modifying Agents drug class: Fumarates |
TECFIDERA*Dimethyl Fumarate Capsule Delayed Release |
MS Disease Modifying Agents drug class: Fumarates |
VUMERITY*Diroximel Fumarate Capsule Delayed Release |
MS Disease Modifying Agents drug class: Glatiramer |
|
MS Disease Modifying Agents drug class: Glatiramer |
COPAXONE*Glatiramer Acetate Soln Prefilled Syringe |
MS Disease Modifying Agents drug class: Glatiramer |
GLATOPA*Glatiramer Acetate Soln Prefilled Syringe |
MS Disease Modifying Agents drug class: IgG4k monoclonal antibody |
|
MS Disease Modifying Agents drug class: IgG4k monoclonal antibody |
TYSABRI*Natalizumab for IV Inj Conc |
MS Disease Modifying Agents drug class: Interferons |
|
MS Disease Modifying Agents drug class: Interferons |
AVONEX*Interferon beta-1a injection |
MS Disease Modifying Agents drug class: Interferons |
BETASERON*Interferon beta-1b injection |
MS Disease Modifying Agents drug class: Interferons |
EXTAVIA*Interferon beta-1b injection |
MS Disease Modifying Agents drug class: Interferons |
PLEGRIDY*Peginterferon beta-1a injection |
MS Disease Modifying Agents drug class: Interferons |
REBIF*Interferon Beta- |
MS Disease Modifying Agents drug class: Purine antimetabolite |
|
MS Disease Modifying Agents drug class: Purine antimetabolite |
MAVENCLAD*Cladribine Tab Therapy Pack |
MS Disease Modifying Agents drug class: Pyrimidine synthesis inhibitor |
|
MS Disease Modifying Agents drug class: Pyrimidine synthesis inhibitor |
AUBAGIO*Teriflunomide Tab |
MS Disease Modifying Agents drug class: Sphingosine 1-phosphate (SIP) receptor modulator |
|
MS Disease Modifying Agents drug class: Sphingosine 1-phosphate (SIP) receptor modulator |
GILENYA*Fingolimod HCl Cap |
MS Disease Modifying Agents drug class: Sphingosine 1-phosphate (SIP) receptor modulator |
MAYZENT*Siponimod Fumarate Tab |
MS Disease Modifying Agents drug class: Sphingosine 1-phosphate (SIP) receptor modulator |
PONVORY*Ponesimod Tab |
MS Disease Modifying Agents Drug Class: Sphingosine 1-phosphate (SIP) receptor modulator |
|
MS Disease Modifying Agents Drug Class: Sphingosine 1-phosphate (SIP) receptor modulator |
TASCENSO*fingolimod lauryl sulfate tablet disintegrating |
MS Disease Modifying Agents drug class: Sphingosine 1-phosphate (SIP) receptor modulator |
|
MS Disease Modifying Agents drug class: Sphingosine 1-phosphate (SIP) receptor modulator |
ZEPOSIA*Ozanimod capsule |
CONTRAINDICATION AGENTS
Contraindicated as Concomitant Therapy |
Examples of Contraindicated Concomitant Disease Modifying Agents (DMAs) * -generic available |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
Commercial _ CSReg _ Multiple_Sclerosis_Agents_STQL _ProgSum_ 10-01-2024 _ _v2