Zeposia (ozanimod) — CareFirst (Caremark)

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

Initial criteria

Relapsing Forms of Multiple Sclerosis: member has been diagnosed with a relapsing form of multiple sclerosis (including relapsing‑remitting and secondary progressive disease for those who continue to experience relapse)
Clinically Isolated Syndrome: member is diagnosed with clinically isolated syndrome of multiple sclerosis
Ulcerative Colitis: member has moderately to severely active ulcerative colitis
Medication must be prescribed by or in consultation with an appropriate specialist (neurologist for multiple sclerosis or gastroenterologist for ulcerative colitis)
Member cannot use Zeposia concomitantly with immunomodulators, biologic drugs, targeted synthetic drugs, or disease modifying multiple sclerosis agents for the same indication (Ampyra and Nuedexta are not considered disease modifying)
For multiple sclerosis: authorization may be granted for pediatric members age <18 years when benefits outweigh risks

Relapsing Forms of Multiple Sclerosis and Clinically Isolated Syndrome: member is experiencing disease stability or improvement while receiving Zeposia
Ulcerative Colitis: member achieves or maintains remission OR maintains a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms with improvement from baseline in any of the following: stool frequency, rectal bleeding, urgency of defecation, C‑reactive protein (CRP), fecal calprotectin (FC), appearance of mucosa on endoscopy/CTE/MRE/intestinal ultrasound, or improvement on a disease activity scoring tool such as UCEIS or Mayo score

12 months