Tascenso ODT 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 syndrome, or active secondary progressive disease
- member has experienced therapeutic failure or intolerance to plan-preferred generic fingolimod capsules OR member has an inability to swallow capsules
Reauthorization criteria
- prescriber attests member has experienced a therapeutic response defined as disease stability OR disease improvement OR delayed disease progression
- member has experienced therapeutic failure or intolerance to plan-preferred generic fingolimod capsules OR member has an inability to swallow capsules
Approval duration
24 months