Fingolimod (Gilenya®)


Indications for Prior Authorization:

  • Relapsing remitting multiple sclerosis (RRMS)

Gilenya is a preferred disease modifying agent for the treatment of relapsing forms of multiple sclerosis when all criteria below are met.

Patients must meet the following criteria for the indication(s) above:

  • Diagnosis confirmed by a neurologist, AND
  • This drug may not be used in combination with any other disease-modifying therapy for MS, either oral or injectable, AND
  • In last 6 months patient has not experienced myocardial infarction, unstable angina, stroke, TIA, decompensated heart failure requiring hospitalization or Class III/IV heart failure, AND
  • Patient does not have a history of Mobitz Type II second or third-degree AV block or sick sinus syndrome (unless patient has a pacemaker), AND
  • Patient is not using in combination with Class Ia or Class III anti-arrhythmic drugs

This medication is not approvable for the following condition(s):

  • Any condition not listed above does not meet WHA criteria for approval


  • Fingolimod 0.5 mg once daily


  • Initial approval for one year
  • Renew for one year if patient has clinical response


Last review date: December 2, 2013

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