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The Policy VaultThe Policy Vault

Aubagio (brand) — Cigna

Multiple Sclerosis

Initial criteria

  • Patient meets the standard Multiple Sclerosis – Teriflunomide Prior Authorization Policy criteria; AND
  • Patient meets ONE of the following (i or ii):
  • i. Patient meets BOTH of the following (a and b):
  • a) Patient has been established on Aubagio (brand or generic) for ≥ 120 days; AND
  • b) Patient meets BOTH of the following [(1) and (2)]:
  • (1) Patient has tried generic teriflunomide tablets [documentation required]; AND
  • (2) Patient cannot continue to use generic teriflunomide tablets due to a formulation difference in the inactive ingredient(s) [e.g., differences in dyes, fillers, preservatives] which would result in a significant allergy or serious adverse reaction [documentation required]; OR
  • ii. Patient meets ALL of the following (a, b, c, and d):
  • a) Patient meets BOTH of the following [(1) and (2)]:
  • (1) Patient has tried generic dimethyl fumarate delayed-release capsules [documentation required]; AND
  • (2) Patient has experienced inadequate efficacy or significant intolerance according to the prescriber [documentation required];
  • Note: Prior use of Tecfidera, Bafiertam, or Vumerity with inadequate efficacy or significant intolerance (according to the prescriber) also counts; AND
  • b) Patient meets BOTH of the following [(1) and (2)]:
  • (1) Patient has tried generic glatiramer injection [documentation required]; AND
  • (2) Patient has experienced inadequate efficacy or significant intolerance according to the prescriber [documentation required];
  • Note: Prior use of Copaxone or Glatopa with inadequate efficacy or significant intolerance also counts; AND
  • c) Patient meets BOTH of the following [(1) and (2)]:
  • (1) Patient has tried generic fingolimod capsules [documentation required]; AND
  • (2) Patient has experienced inadequate efficacy or significant intolerance according to the prescriber; AND
  • d) Patient meets BOTH of the following [(1) and (2)]:
  • (1) Patient has tried generic teriflunomide tablets [documentation required]; AND
  • (2) Patient cannot continue to use generic teriflunomide tablets due to a formulation difference in the inactive ingredient(s) that would result in a significant allergy or serious adverse reaction [documentation required].

Approval duration

1 year