Tecfidera (dimethyl fumarate delayed-release capsules - Biogen, generic) — Cigna

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

Initial criteria

Patient has a relapsing form of multiple sclerosis; 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 experienced a beneficial clinical response when assessed by at least one objective measure (e.g., stabilization or reduced worsening in MRI activity, EDSS score, NEDA-3 or NEDA-4 metrics, fatigue symptom and impact questionnaire, reduction or absence of relapses, improvement or maintenance on walking tests, MSFC score, attenuation of brain volume loss); OR
Patient experienced stabilization, slowed progression, or improvement in at least one symptom such as 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