Bafiertam (monomethyl fumarate delayed-release capsules) — Cigna
Multiple sclerosis (relapsing forms including clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease)
Initial criteria
- Patient has a relapsing form of multiple sclerosis; AND
- Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis
Reauthorization criteria
- Patient has a relapsing form of multiple sclerosis; AND
- Patient experienced a beneficial clinical response when assessed by at least one objective measure OR patient experienced stabilization, slowed progression, or improvement in at least one symptom such as motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or pain/numbness/tingling sensation; AND
- Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis
Approval duration
1 year