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Mavenclad (cladribine) — Blue Cross Blue Shield of New Mexico

Relapsing-remitting multiple sclerosis (RRMS)

Initial criteria

  • The requested agent is eligible for continuation of therapy AND the following: prescriber states the patient has been treated with the requested agent within the past 90 days AND the patient is at risk if therapy is changed OR BOTH of the following apply:
  • 1. The patient has ONE of the following relapsing forms of multiple sclerosis (MS): Relapsing-remitting disease (RRMS) OR Active secondary progressive disease (SPMS)
  • 2. If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication
  • If the patient has been previously treated with the requested agent, then BOTH of the following: (A) The prescriber has provided the number of courses the patient has completed (one course consists of 2 cycles of 4–5 days each) AND (B) The patient has NOT completed 2 courses of the requested agent (one course consists of 2 cycles of 4–5 days each)
  • A complete CBC with differential including lymphocyte count has been performed AND the lymphocyte count is within normal limits
  • The prescriber is a specialist in the area of the patient’s diagnosis (i.e., neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
  • ONE of the following: (A) The patient will NOT be using the requested agent with an additional disease modifying agent (DMA) for the requested indication OR (B) BOTH of the following: (1) The patient is currently using the requested agent AND (2) Information has been provided supporting the use of the additional DMA (e.g., relapse between cycles)
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • The requested quantity (dose) does NOT exceed the FDA labeled maximum dose based on the patient's weight

Approval duration

12 months for BCBSIL, BCBSMT, and BCBSTX (two courses allowed); 36 weeks for new starts under all other plans or remainder of annual course if continuing