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Tecfidera (dimethyl fumarate) — Highmark

Relapsing forms of multiple sclerosis (clinically isolated syndrome, relapsing-remitting disease, or active secondary progressive disease)

Preferred products

  • generic dimethyl fumarate

Initial criteria

  • age ≥ 18 years
  • Diagnosis of multiple sclerosis (ICD-10: G35) classified as a relapsing form (clinically isolated syndrome, relapsing-remitting disease, or active secondary progressive disease)
  • If the request is for brand Tecfidera, member has experienced therapeutic failure or intolerance to generic dimethyl fumarate
  • If the request is for Bafiertam or Vumerity, member has experienced therapeutic failure or intolerance to plan-preferred generic dimethyl fumarate

Reauthorization criteria

  • Prescriber attests that member has experienced a therapeutic response defined as one of the following: disease stability OR disease improvement OR delayed disease progression
  • If the request is for brand Tecfidera, member has experienced therapeutic failure or intolerance to generic dimethyl fumarate
  • If the request is for Bafiertam or Vumerity, member has experienced therapeutic failure or intolerance to plan-preferred generic dimethyl fumarate

Approval duration

24 months