Gilenya 0.25 mg — Highmark
multiple sclerosis (ICD-10: G35): active secondary progressive disease
Preferred products
- generic fingolimod capsules
Initial criteria
- age 10–17 years
- weight ≤ 40 kg
- diagnosis of multiple sclerosis (ICD-10: G35) classified as one of the following: clinically isolated syndrome, relapsing-remitting disease, or active secondary progressive disease
Reauthorization criteria
- prescriber attests member has experienced a therapeutic response defined as disease stability OR disease improvement OR delayed disease progression
- age 10–17 years
- weight ≤ 40 kg
Approval duration
24 months