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Tascenso ODT (fingolimod) — Blue Cross Blue Shield of Oklahoma

Relapsing forms of multiple sclerosis (MS)

Preferred products

  • Avonex (interferon β-1a)
  • Betaseron (interferon β-1b)
  • dimethyl fumarate
  • glatiramer
  • Glatopa (glatiramer)
  • Kesimpta (ofatumumab)
  • Mayzent (siponimod)
  • Rebif (interferon β-1a)
  • teriflunomide
  • Zeposia (ozanimod)

Initial criteria

  • 1. ONE of the following:
  • A. The requested agent is eligible for continuation of therapy AND the following: 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.
  • Agents eligible for continuation of therapy: all target agents except Brand Aubagio, Brand Copaxone, Brand Gilenya 0.5 mg, and Brand Tecfidera.
  • OR
  • B. BOTH of the following:
  • 1. ONE of the following:
  • A. The patient has a diagnosis of a relapsing form of MS AND ALL of the following:
  • 1. 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 prescriber states the patient is currently being treated with the requested agent AND the patient is currently stable (chart notes required) OR
  • 2. The patient is age ≤ 17 years AND ONE of the following:
  • A. The requested agent is one of the following brand agents that does NOT have an equipotent generic strength: Gilenya 0.25 mg, Tascenso ODT 0.25 mg OR
  • B. The patient has tried and had an inadequate response to generic fingolimod (medical records required) OR
  • C. Generic fingolimod was discontinued due to lack of efficacy or adverse event (chart notes required) OR
  • D. The patient has an intolerance or hypersensitivity to generic fingolimod (medical records required) OR
  • E. The patient has an FDA labeled contraindication to generic fingolimod (medical records required) OR
  • F. Generic fingolimod is expected to be ineffective or cause harm based on known clinical characteristics (chart notes required) OR
  • G. Generic fingolimod is not in the best interest of the patient based on medical necessity (chart notes required) OR
  • H. The patient has tried another drug in the same class as fingolimod that was discontinued due to inefficacy or adverse event (chart notes required) OR
  • I. If the requested agent is Tascenso ODT 0.5 mg, there is support for use over generic fingolimod (e.g., swallowing difficulties).
  • 3. The patient is age ≥ 18 years AND BOTH of the following:
  • A. ONE of the following:
  • 1. The patient has tried and had an inadequate response to TWO preferred agents that are FDA-labeled for the indication (medical records required) OR
  • 2. TWO preferred agents were discontinued due to lack of efficacy or adverse event (chart notes required) OR
  • 3. The patient has an intolerance or hypersensitivity to TWO preferred agents (chart notes required) OR
  • 4. The patient has an FDA labeled contraindication to ALL preferred agents (chart notes required) OR
  • 5. TWO preferred agents are expected to be ineffective or cause harm or barrier to adherence (chart notes required) OR
  • 6. TWO preferred agents are not in the best interest based on medical necessity (chart notes required) OR
  • 7. The patient has tried another drug in the same class as TWO preferred agents that was discontinued due to inefficacy or adverse event (chart notes required) AND
  • B. If the requested agent is Tascenso ODT 0.5 mg, ONE of the following:
  • 1. The patient has tried and had an inadequate response to generic fingolimod (medical records required) OR
  • 2. Generic fingolimod was discontinued due to lack of efficacy or adverse event (chart notes required) OR
  • 3. The patient has an intolerance or hypersensitivity to generic fingolimod not expected with the requested agent OR
  • 4. The patient has an FDA labeled contraindication to generic fingolimod not expected with the requested agent OR
  • 5. Generic fingolimod is expected to be ineffective or cause harm (chart notes required) OR
  • 6. Generic fingolimod is not in the best interest of the patient based on medical necessity (chart notes required) OR
  • 7. The patient has tried another drug in the same class as generic fingolimod that was discontinued due to inefficacy or adverse event (chart notes required) OR
  • 8. There is support for the use of the requested agent over generic fingolimod (e.g., swallowing difficulties).
  • 4. The patient has highly active MS disease activity AND ONE of the following (medical records including chart notes required): A. The patient has ≥2 relapses in the previous year.

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through prior authorization AND
  • 2. The patient has had clinical benefit with the requested agent AND
  • 3. A complete CBC with differential including lymphocyte count has been performed AND lymphocyte count ≥ 800 cells/microliter AND
  • 4. The prescriber is a neurologist or has consulted with a neurologist AND
  • 5. ONE of the following: (A) The patient will NOT use the requested agent in combination with another DMA OR (B) There is support for the additional DMA use (e.g., relapse between cycles) AND
  • 6. The patient has no FDA labeled contraindications to the requested agent AND
  • 7. It has been at least 35 weeks but not more than 67 weeks since the last dose AND
  • 8. BOTH of the following: (A) The prescriber provided the number of courses completed AND (B) The patient has NOT completed 2 courses (each consisting of 2 cycles of 4-5 days) AND
  • 9. The requested dose does not exceed maximum FDA labeled dose for weight.

Approval duration

12 months