Vumerity (diroximel fumarate) — United Healthcare

relapsing-remitting MS

Preferred products

Diagnosis of clinically isolated syndrome (CIS) or a relapsing form of multiple sclerosis (MS) (e.g., relapsing-remitting MS, secondary progressive MS with relapses)
Prescribed by or in consultation with a specialist in the treatment of MS (e.g., neurologist)
Submission of medical records documenting the trial and failure (after trial of at least 4 weeks), contraindication, or intolerance to at least two of the following: glatiramer acetate (e.g., Copaxone), interferon β-1a (e.g., Avonex, Rebif), interferon β-1b (e.g., Betaseron), peginterferon β-1a (Plegridy), teriflunomide (Aubagio), Mayzent (siponimod), fingolimod (Gilenya), Zeposia (ozanimod), Kesimpta (ofatumumab)
Submission of medical records documenting the trial and failure (after trial of at least 4 weeks), contraindication, or intolerance to both of the following: Bafiertam (monomethyl fumarate) AND dimethyl fumarate (generic Tecfidera) with trial date that started August 20, 2020 or later
Patient is not receiving Vumerity in combination with another disease modifying therapy for multiple sclerosis [e.g., interferon beta preparations, glatiramer acetate, dimethyl fumarate (Tecfidera), Tysabri (natalizumab), fingolimod (Gilenya), Ocrevus (ocrelizumab), Lemtrada (alemtuzumab), Mavenclad (cladribine), teriflunomide (Aubagio), Bafiertam (monomethyl fumarate), Kesimpta (ofatumumab), Zeposia (ozanimod), or Mayzent (siponimod)]

12 months