Indications for Prior Authorization
- relapsing remitting multiple sclerosis (RRMS)
Patients must meet the following criteria for the indications above.
This drug may not be used in combination with each other or any other disease modifying therapy for MS, either oral or injectable.
Any condition not listed above does not meet WHA criteria for approval.
- fingolimod 0.5 mg twice a day
- Initial approval for one year.
- Renew for one year if patient has clinical response.
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: January 2011 Reviewed: December 2013