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Gilenya — Blue Cross Blue Shield of Kansas

relapsing multiple sclerosis

Preferred products

  • Avonex
  • Betaseron
  • Copaxone
  • Extavia
  • Glatopa
  • Plegridy
  • Rebif

Initial criteria

  • ONE of the following: (A) The requested agent is eligible for continuation of therapy AND ONE of the following: (1) The patient has been treated with the requested agent within the past 90 days OR (2) The prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed OR (B) BOTH of the following: (1) The patient has a diagnosis of a relapsing form of multiple sclerosis AND (2) ONE of the following: (A) The requested agent is a preferred agent OR (B) The requested agent is a non-preferred agent AND ONE of the following: (1) The patient is age ≤ 17 years AND ONE of the following: (A) The request is for one of the brand agents that does NOT have an equipotent preferred generic strength (Gilenya 0.25 mg or Tascenso ODT 0.25 mg) OR (B) The patient has tried and had an inadequate response to generic fingolimod (medical records required)