Tecfidera (brand) — Cigna
multiple sclerosis
Preferred products
- generic dimethyl fumarate delayed-release capsules
Initial criteria
- Patient meets BOTH of the following (A and B):
- A) Patient meets the standard Multiple Sclerosis – Dimethyl Fumarate Prior Authorization Policy criteria; AND
- B) Patient meets BOTH of the following (i and ii):
- i. Patient has tried generic dimethyl fumarate delayed-release capsules [documentation required]; AND
- ii. Patient cannot continue to use generic dimethyl fumarate delayed-release capsules due to a formulation difference in inactive ingredient(s) [e.g., 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].
Approval duration
1 year