Vumerity — CareFirst (Caremark)
Relapsing forms of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse)
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