CurrentCignaPolicy N/A

Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Fingolimod Prior Authorization Policy

Defines prior authorization requirements and coverage criteria for fingolimod (Gilenya and generic) for treatment of relapsing forms of multiple sclerosis for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyFingolimod (Gilenya) prior authorization for multiple sclerosis

Policy CodePolicy N/A

Change TypeAdded age ≥ 10 years requirementpolicy renamed to clarify oral S1P modulator

Effective DateN/A

Next Review DateJul 23, 2025

Key ActionObtain prior authorization; ensure medication is prescribed by or in consultation with a neurologist or MS specialist and document criteria to approve for 1 year.

SourceLink

POLICY UPDATE CHANGES

Added requirement that the patient is ≥ 10 years of age for both initial and continuation therapy.

Policy name changed to add 'Oral - Sphingosine 1-Phosphate Receptor Modulator'.

≥10Minimum age eligible for fingolimod

1 yearApproval duration

PAUtilization requirement

NMIConcurrent DMTs

Coverage Criteria for Fingolimod (Gilenya)

Policy Summary

PayerCigna

PolicyFingolimod (Gilenya) prior authorization for multiple sclerosis

Policy CodePolicy N/A

Change TypeAdded age ≥ 10 years requirementpolicy renamed to clarify oral S1P modulator

Effective DateN/A

Next Review DateJul 23, 2025

Key ActionObtain prior authorization; ensure medication is prescribed by or in consultation with a neurologist or MS specialist and document criteria to approve for 1 year.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medication and Related Codes

Covered medication examplesmixedCovered

Gilenya (fingolimod) capsules	Gilenya ® (fingolimod capsules - Novartis, generic)
Tascenso ODT (fingolimod orally disintegrating tablets)	Tascenso ODT ® (fingolimod orally disintegrating tablets)

Covered medication examples (alternate listing)mixedCovered

Gilenya (fingolimod) capsules

Gilenya ® (fingolimod capsules, generic)

Examples of other disease-modifying agentsmixed

Various DMTs

Appendix lists multiple disease-modifying therapies (e.g., Aubagio, Avonex, Briumvi, Kesimpta, Mayzent, Ocrevus, Ponvory, Tecfidera, Zeposia, etc.)

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required for fingolimod (Gilenya®). Approvals are generally provided for 1 year. Because of the specialized skills required for evaluation, diagnosis, and monitoring of patients treated with fingolimod, the medication must be prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.

Approval duration: 1 year for initial and renewal authorizations
Prescriber requirement: Prescribed by or in consultation with a neurologist or MS specialist

Step Therapy

Treatment Sequencing / Concurrent Use

Fingolimod is approved as monotherapy for relapsing forms of multiple sclerosis. Concurrent use of fingolimod with other disease-modifying therapies (DMTs) for multiple sclerosis is considered not medically necessary and is not permitted. See the Appendix for examples of other DMTs.

Concurrent DMTs: Combination use with other disease-modifying agents for MS is not allowed
Appendix: Lists other DMTs (e.g., interferons, glatiramer acetate, ocrelizumab, ofatumumab, siponimod, ponesimod, cladribine, alemtuzumab, etc.)

Documentation Required

Prescriber and Approval Duration

Approval and continuation criteria require that fingolimod be prescribed by or in consultation with a neurologist or physician who specializes in MS. Initial approvals (for patients starting fingolimod) and renewals (for patients currently receiving fingolimod) are generally authorized for 1 year when clinical criteria are met.

Initial therapy: Approve for 1 year when patient has a relapsing form of MS, is ≥ 10 years old, and medication is prescribed by or in consultation with a neurologist/MS specialist
Continuation therapy: Approve for 1 year for patients currently receiving fingolimod for ≥ 1 year who have a relapsing form of MS, are ≥ 10 years old, and demonstrate clinical benefit

Denial Risk

Concurrent DMTs Not Allowed

Concurrent use of fingolimod with other disease-modifying agents used for multiple sclerosis is considered not medically necessary due to lack of evidence of safety and added efficacy for combination therapy.

Concurrent use with other DMTs is listed under Conditions Not Covered
Refer to Appendix for examples of agents not to be used in combination

Definitions

Relapsing MS defined / key definition(s)

DefinitionRelapsing forms of multiple sclerosis: includes clinically isolated syndrome, relapsing‑remitting MS, and active secondary progressive MS.

Age thresholdPatient is \u2265 10 years of age for initiation or continuation of fingolimod therapy.

Therapy scopeIndication applies to treatment with fingolimod (oral sphingosine 1‑phosphate receptor modulator).

Clinical monitoring noteInitiation requires appropriate monitoring due to first‑dose cardiac effects (see safety guidance).

Excluded populations (implicit)Non‑relapsing forms of MS (eg, primary progressive) are not within the relapsing MS indication described.

OpenPayer

Multiple Sclerosis (Oral - Sphingosine 1-Phosphate Receptor Modulator) - Fingolimod Prior Authorization Policy

Coverage Criteria for Fingolimod (Gilenya)

Medication and Related Codes

Provider Actions and Authorization Requirements

Definitions

Background