Dimethyl fumarate capsules — Medical Mutual

Multiple Sclerosis (MS) – relapsing forms including clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease

Initial criteria

Patient has a relapsing form of multiple sclerosis; AND
Patient age ≥ 18 years; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Reauthorization criteria

Patient has a relapsing form of multiple sclerosis; AND
Patient meets one of the following: (a) Beneficial clinical response assessed by at least one objective measure (e.g., MRI lesion reduction or stabilization, EDSS stabilization, NEDA-3 or NEDA-4, FSIQ-RMS improvement, reduction/absence of relapses, walking test improvement, MSFC improvement, attenuation of brain volume loss), OR (b) Stabilization, slowed progression, or improvement in ≥ 1 symptom such as motor function, fatigue, vision, bowel/bladder, spasticity, walking/gait, or pain/numbness/tingling; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Approval duration

1 year