Gilenya 0.5 mg — Highmark
multiple sclerosis (ICD-10: G35): active secondary progressive disease
Preferred products
- generic fingolimod capsules
Initial criteria
- age ≥ 10 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
- if request is for brand Gilenya, member has experienced therapeutic failure or intolerance to generic fingolimod
Reauthorization criteria
- prescriber attests member has experienced a therapeutic response defined as disease stability OR disease improvement OR delayed disease progression
- if request is for brand Gilenya, member has experienced therapeutic failure or intolerance to generic fingolimod
Approval duration
24 months