Mayzent (siponimod) — Highmark
Relapsing forms of multiple sclerosis (clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease)
Initial criteria
- age ≥ 18 years
- Diagnosis of multiple sclerosis (ICD-10: G35) classified as clinically isolated syndrome OR relapsing-remitting disease OR active secondary progressive disease
- Member has been tested for CYP2C9 variants to determine CYP2C9 genotype
- Member does not have a CYP2C9• 3/• 3 genotype
Reauthorization criteria
- Prescriber attests that the member has experienced a therapeutic response defined as disease stability OR disease improvement OR delayed disease progression
Approval duration
24 months