Health Net
Mavenclad (4 Tabs) (cladribine(multiple sclerosis))
Drugs for the Nervous System : Drugs for Multiple Sclerosis
  • Step Therapy Applies
  • Quantity Limit: limit maximum 4 EA PER 30 day(s)
  • Prior Authorization: Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Multiple Sclerosis (MS):
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Neurologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Patients Cardiac Medical History Required: No
    Concomitant use of other MS medication: No
    Supporting Documentation Requirements: 3 of Chart Notes;Documentation of baseline number of relapses per year;Documentation of expanded disability status scale (EDSS) score

    Secondary Progressive Multiple Sclerosis:
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Neurologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

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