UnitedHealthcare
Mavenclad (10 Tabs) (cladribine(multiple sclerosis))
Drugs for the Nervous System : Drugs for Multiple Sclerosis
  • Step Therapy: Multiple Sclerosis (MS):
    ST Single Generic

    Secondary Progressive Multiple Sclerosis:
    ST Single Brand

  • Multiple Sclerosis (MS):
    Duration: 2 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 2 month(s)
    Patients Cardiac Medical History Required: No
    Concomitant use of other MS medication: No

    Secondary Progressive Multiple Sclerosis:
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Neurologist
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified

  • Prior Authorization: Multiple Sclerosis (MS):
    Documented Diagnosis: Yes
    Duration: 2 Month(s)
    Reauthorization Required: Yes

    Secondary Progressive Multiple Sclerosis:
    Documented Diagnosis: Yes
    Reauthorization Required: Yes

  • Quantity Limit: limit maximum 40 EA PER 720 day(s)
<< Return | Back to top