Dimethyl fumarate (Tecfidera®)

Self administered

Indications for Prior Authorization

Relapsing forms of multiple sclerosis

All of the following must be met as a condition for coverage

This Medication is Not Approvable for the following condition(s).

Any condition not listed above as an approved indication.


Starting dose: 120 mg twice a day x 7 days.

Maintenance dose: 240mg twice a day

Duration of Therapy

initial authorization: one year

Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: May 2013 | Reviewed: December 3, 2013