Dimethyl fumarate (Tecfidera®)
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