Gilenya (fingolimod capsules - Novartis, generic) — Cigna

Relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease)

Initial criteria

Patient has a relapsing form of multiple sclerosis; AND
Patient age ≥ 10 years; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Patient has a relapsing form of multiple sclerosis; AND
Patient age ≥ 10 years; AND
Patient meets ONE of the following (a or b):
a) Patient experienced a beneficial clinical response when assessed by at least one objective measure (e.g., stabilization or reduced worsening in disease activity as evaluated by MRI, stabilization or improvement in EDSS score, achievement in criteria for NEDA-3 or NEDA-4, improvement in MS functional assessments, reduction or absence of relapses, attenuation of brain volume loss); OR
b) Patient experienced stabilization, slowed progression, or improvement in at least one symptom (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

1 year