Mavenclad (cladribine tablets) — Cigna

Initial criteria

• Patient meets ONE of the following (1, 2, or 3):
• 1) According to the prescriber, patient has experienced inadequate efficacy or significant intolerance to two disease-modifying agents used for multiple sclerosis; OR
• 2) According to the prescriber, patient has experienced inadequate efficacy or significant intolerance to ONE of the following: Kesimpta (ofatumumab subcutaneous injection), a natalizumab intravenous product (Tysabri, biosimilar), Briumvi (ublituximab-xiiy intravenous infusion), Lemtrada (alemtuzumab intravenous infusion), Ocrevus (ocrelizumab intravenous infusion), or Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq subcutaneous injection); OR
• 3) Patient has received Mavenclad in the past.
• Exception: Patient has highly-active or aggressive multiple sclerosis by meeting ONE of the following [(1), (2), (3), or (4)]:
• 1) Patient has demonstrated rapidly advancing deterioration(s) in physical functioning (documentation required); OR
• 2) Disabling relapse(s) with suboptimal response to systemic corticosteroids (documentation required); OR
• 3) MRI findings suggest highly active or aggressive multiple sclerosis (documentation required); OR
• 4) Manifestations of multiple sclerosis-related cognitive impairment (documentation required).