Mavenclad (cladribine) — CareFirst (Caremark)

Relapsing forms of multiple sclerosis (including relapsing-remitting disease and active secondary progressive disease)

Initial criteria

Authorization of 45 days may be granted for treatment of relapsing forms of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapses) AND all of the following:
Inadequate response or unable to tolerate an alternative drug indicated for the treatment of multiple sclerosis.
Member does not have clinically isolated syndrome (CIS).
Member has not received 2 courses (i.e., 4 cycles) of Mavenclad.

Authorization of 45 days may be granted for treatment of relapsing forms of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapses) AND all of the following:
Member has not received 2 courses (i.e., 4 cycles) of Mavenclad.
The member has not received Mavenclad in the last 43 weeks.

45 days