Mavenclad — Medical Mutual

Initial criteria

• Patient has a relapsing form of multiple sclerosis; AND
• Patient meets ONE of the following (a, b, or c):
• a) According to the prescriber, patient has experienced inadequate efficacy or significant intolerance to two disease-modifying agents used for multiple sclerosis; OR
• b) According to the prescriber, patient has experienced inadequate efficacy or significant intolerance to ONE of Kesimpta (ofatumumab subcutaneous injection), a natalizumab intravenous product (Tysabri, biosimilar), Briumvi (ublituximab-xiiy intravenous infusion), Lemtrada (alemtuzumab intravenous infusion), Ocrevus (ocrelizumab intravenous infusion) or Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq subcutaneous injection); OR
• c) Patient has received Mavenclad in the past; AND
• The 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 or b):
• a) Patient experienced a beneficial clinical response when assessed by at least one objective measure (e.g., stabilization or reduced worsening in disease activity on MRI, EDSS score, NEDA-3/4 criteria, symptom scales, relapse reduction, or functional measures); OR
• b) Patient experienced stabilization, slowed progression, or improvement in at least one symptom such as motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or pain/numbness/tingling; AND
• The medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Approval duration

365 days