Western Health Advantage
Vumerity (Starter) (diroximel fumarate)
Drugs for the Nervous System : Drugs for Multiple Sclerosis
  • Lupus Nephritis:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)

    Systemic Lupus Erythematosus (SLE):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    SELENA-SLEDAI Score Required: N/A
    Reauthorization SELENA-SLEDAI Score Required: N/A
    Does Policy Include Excluded Indications: No

  • Prior Authorization: Reduction of CV events in CAD/PAD:
    Duration: 1 year(s)

  • Quantity Limit: limit maximum 21 EA PER 28 day(s)
  • Quantity Limit: limit maximum 1,575 ML PER 28 day(s)