Gilenya (brand) — Cigna

Multiple Sclerosis

Initial criteria

Patient meets the standard Multiple Sclerosis – Fingolimod Prior Authorization Policy criteria; AND
Patient meets BOTH of the following (i and ii):
i. Patient meets ONE of the following (a, b, or c):
a) Patient has been established on Gilenya (brand or generic) for ≥ 120 days; OR
b) Patient age ≥ 10 to < 18 years; OR
c) 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 [documentation required]; AND
ii. Patient meets BOTH of the following (a and b):
a) Patient has tried generic fingolimod capsules [documentation required]; AND
b) Patient cannot continue to use generic fingolimod capsules due to a formulation difference in the inactive ingredient(s) [e.g., differences in dyes, fillers, preservatives] between the Brand and the bioequivalent generic which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required].

1 year