Mayzent (siponimod) — CareFirst (Caremark)
Relapsing forms of multiple sclerosis (including relapsing-remitting and active secondary progressive disease)
Initial criteria
- Member has a diagnosis of a relapsing form of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse) OR clinically isolated syndrome
- Medication is prescribed by or in consultation with a neurologist
- Member will not use Mayzent concomitantly with other disease modifying multiple sclerosis agents (Ampyra and Nuedexta are not considered disease modifying)
Reauthorization criteria
- Member is experiencing disease stability or improvement while receiving Mayzent
Approval duration
12 months