Tascenso ODT — Cigna

Multiple Sclerosis

Initial criteria

Patient meets the standard Multiple Sclerosis – Tascenso ODT Prior Authorization Policy criteria; AND
Patient meets BOTH of the following (i and ii):
i. Patient meets ONE of the following (a, b, c, or d):
a) Patient cannot swallow or has difficulty swallowing tablets or capsules; OR
b) Patient has been established on Tascenso ODT for ≥ 120 days; OR
c) Patient age ≥ 10 to < 18 years; OR
d) 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 also counts [documentation required]; AND
ii. Patient meets ONE of the following (a or b):
a) Patient meets BOTH of the following (i and ii):
i. Patient has tried generic fingolimod capsules [documentation required]; AND
ii. Patient cannot continue to use generic fingolimod capsules due to a formulation difference in the inactive ingredient(s) that would result in a significant allergy or serious adverse reaction [documentation required]; OR
b) Patient cannot swallow or has difficulty swallowing tablets or capsules.

1 year