Zeposia (ozanimod capsules – Celgene) — Cigna

Relapsing forms of multiple sclerosis

Initial criteria

For multiple sclerosis: Patient has a relapsing form of multiple sclerosis (e.g., clinically isolated syndrome, relapsing remitting disease, or active secondary progressive disease) AND the medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.
For ulcerative colitis: Patient age ≥ 18 years AND the medication is prescribed by or in consultation with a gastroenterologist.

For multiple sclerosis: Patient has a relapsing form of multiple sclerosis AND has experienced a beneficial clinical response when assessed by at least one objective measure (e.g., MRI lesion reduction, stabilization or improvement in disability or symptoms) OR has 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). AND the medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.
For ulcerative colitis: Patient has been established on therapy for at least 6 months AND has experienced a beneficial clinical response from baseline when assessed by objective measures (e.g., fecal markers, serum markers, endoscopic assessment, or reduced corticosteroid dose) OR has experienced improvement in at least one symptom (decreased pain, fatigue, stool frequency, and/or decreased rectal bleeding).

initial: 1 year (MS); 6 months (UC); reauth: 1 year