Vumerity — CareFirst (Caremark)

Initial criteria

• Diagnosis of a relapsing form of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse)
• OR diagnosis of clinically isolated syndrome
• Medication prescribed by or in consultation with a neurologist
• Member will not use Vumerity concomitantly with other disease modifying multiple sclerosis agents (Ampyra and Nuedexta are not considered disease modifying)
• Authorization may be granted for pediatric members age < 18 years when benefits outweigh risks

Reauthorization criteria

• Member is experiencing disease stability or improvement while receiving Vumerity

Approval duration

12 months