Health Net |
Vumerity (Starter) (diroximel fumarate) |
Drugs for the Nervous System : Drugs for Multiple Sclerosis |
- Step Therapy Applies
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Multiple Sclerosis (MS):
Age Requirement: >= 18
Duration: 1 plan year
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;Lab Tests
Secondary Progressive Multiple Sclerosis: Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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