Gilenya (brand) — Medica

multiple sclerosis

Preferred products

Patient meets the standard Multiple Sclerosis – Fingolimod Prior Authorization Policy criteria; AND
Patient meets BOTH of the following (i and ii):
i. Patient meets ONE of the following (a, b, or c): (a) Patient has been established on Gilenya (brand or generic) for ≥ 120 days; OR (b) Patient is ≥ 10 to < 18 years of age; OR (c) Patient meets BOTH of the following [(1) and (2)]: (1) Patient has tried generic dimethyl fumarate delayed-release capsules [documentation required]; AND (2) Patient has experienced inadequate efficacy or significant intolerance according to the prescriber [documentation required]. Note: Prior use of Tecfidera, Bafiertam, or Vumerity with inadequate efficacy or significant intolerance also counts.
ii. Patient meets BOTH of the following (a and b): (a) Patient has tried generic fingolimod capsules [documentation required]; AND (b) Patient cannot continue to use generic fingolimod capsules due to a formulation difference in inactive ingredient(s) which per the prescriber would result in significant allergy or serious adverse reaction [documentation required].

1 year