CurrentCignaPolicy IP0262

Multiple Sclerosis (Oral - Sphingosine 1Phosphate Receptor Modulator) - Mayzent

Defines prior authorization, coverage criteria, and exclusions for Mayzent (siponimod) for treatment of relapsing forms of multiple sclerosis for Cigna-administered health plans.

Policy Summary

PayerCigna

PolicyMultiple Sclerosis (Oral - Sphingosine 1Phosphate Receptor Modulator) - Mayzent

Policy CodePolicy IP0262

Change TypeCriteria additions and revisions (specialist prescribing requirementcontinuation criteriapreferred product updates)

Effective DateThe policy effective date is in force until updated or retired.

Next Review Date

Key ActionObtain prior authorization and ensure medication is prescribed by or in consultation with a neurologist or MS specialist; approvals are for 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Added a specialist prescribing requirement.

Added criteria for patients currently receiving Mayzent for ≥ 1 year.

Updated Individual and Family Plans preferred product criteria.

Updated the conditions not covered statement.

Added a definition for documentation.

Removed Employer Plans preferred product requirements.

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

Ocrevus Zunovo was added to the Appendix.

Removed Extavia from the Appendix.

1 yearapproval duration

≥1 yrcontinuation criterion

Relapsing MS

Policy Summary

PayerCigna

PolicyMultiple Sclerosis (Oral - Sphingosine 1Phosphate Receptor Modulator) - Mayzent

Policy CodePolicy IP0262

Change TypeCriteria additions and revisions (specialist prescribing requirementcontinuation criteriapreferred product updates)

Effective DateThe policy effective date is in force until updated or retired.

Next Review Date

Key ActionObtain prior authorization and ensure medication is prescribed by or in consultation with a neurologist or MS specialist; approvals are for 1 year when criteria are met.

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.

Coverage Criteria for Mayzent (siponimod)

Initial Therapy

Initial Therapy — Approve for 1 year if ALL of the following (Initial Therapy).

ALL of the following

Patient has a relapsing form of multiple sclerosis (examples include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease).
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.
Preferred product criteria is met for the product(s) as listed for Individual and Family Plans (see criteria group for Individual and Family Plans).

Continuation Therapy (Currently Receiving 6gt;= 1 Year)

Continuation Therapy (Currently Receiving 6gt;= 1 Year) — Approve for 1 year if ALL of the following (Currently receiving Mayzent 6gt;= 1 year).

ALL of the following

Patient has a relapsing form of multiple sclerosis (examples include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease).
Clinical benefit
- Patient experienced a beneficial clinical response when assessed by at least one objective measure (examples: stabilization or reduced worsening on MRI such as absence or decrease in gadolinium-enhancing lesions or fewer new/enlarging T2 lesions; stabilization or reduced worsening on EDSS; achievement of NEDA-3 or NEDA-4; improvement on FSIQ-RMS; reduction or absence of relapses; improvement or maintenance on 6-minute walk test or 12-Item MS Walking Scale; improvement on MSFC; attenuation of brain volume loss).
- Patient experienced stabilization, slowed progression, or improvement in at least one symptom (examples: motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or pain/numbness/tingling).
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.

Individual and Family Plans Criteria

For Individual and Family Plans, patient must meet ONE of the following:

ANY of the following

Patient has tried and, according to the prescriber, had inadequate efficacy or significant intolerance to dimethyl fumarate (generic for Tecfidera) [requires prior authorization].
Patient has active secondary progressive multiple sclerosis (SPMS).
Patient is currently receiving Mayzent.

Mayzent should not be used in combination with other disease-modifying agents for multiple sclerosis; concurrent use with other MS disease-modifying therapies is considered not medically necessary due to insufficient evidence of safety and added efficacy. Additionally, use of Mayzent for non-relapsing forms of multiple sclerosis (for example, primary progressive MS) is not medically necessary. Uses outside of the FDA-approved indications are considered not medically necessary.

Coding, Appendix and Reinitiation Rules

Appendix examples of disease-modifying therapies (brand/generic and mode of administration)mixed

Aubagio	teriflunomide tablets — Oral
Avonex	interferon beta-1a intramuscular injection — Injection (self-administered)
Bafiertam	monomethyl fumarate delayed-release capsules — Oral
Betaseron	interferon beta-1b subcutaneous injection — Injection (self-administered)
Briumvi	ublituximab-xiij intravenous infusion — Intravenous infusion
Copaxone	glatiramer acetate subcutaneous injection — Injection (self-administered)
Gilenya	fingolimod capsules — Oral
Glatopa	glatiramer acetate subcutaneous injection — Injection (self-administered)
Kesimpta	ofatumumab subcutaneous injection — Injection (self-administered)
Lemtrada	alemtuzumab intravenous infusion — Intravenous infusion

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Treatment interruption — reinitiation

Reinitiation triggerIf Mayzent therapy is interrupted for ≥ 4 consecutive daily doses, reinitiate treatment starting with Day 1 of the titration regimen.

First-dose monitoring requirementWhen reinitiating after the interruption, complete first-dose monitoring for patients for whom it is recommended (e.g., those with preexisting cardiac conditions).

Titration linkageReinitiation requires repeating the full titration sequence rather than resuming at the prior maintenance dose.

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization is required for benefit coverage of Mayzent. Approvals are provided for 1 year for initial therapy or for patients currently receiving Mayzent for ≥ 1 year when criteria are met. Because of the specialized skills required for evaluation, diagnosis, and monitoring of patients treated with Mayzent, approval requires the medication to be prescribed by or in consultation with a physician who specializes in the treatment of multiple sclerosis.

Prior authorization duration: 1 year for initial therapy; 1 year for continuation when criteria met
Prescriber requirement: neurologist or physician who specializes in the treatment of multiple sclerosis

Step Therapy

Preferred Product / Step Criteria

For Individual and Family Plans, Mayzent (siponimod) is covered when the patient meets ONE of the following: (1) trial and inadequate efficacy or significant intolerance to dimethyl fumarate (generic for Tecfidera) documented and prior authorization for dimethyl fumarate required; (2) diagnosis of active secondary progressive multiple sclerosis (active SPMS); or (3) patient is currently receiving Mayzent. Documentation supporting the chosen criterion must be submitted with the prior authorization request.

Background on Mayzent (siponimod)

Mayzent (siponimod) is an oral sphingosine 1‑phosphate receptor modulator indicated for relapsing forms of multiple sclerosis. The policy explains that efficacy has not been established for non‑relapsing forms of MS and therefore limits coverage to the relapsing presentations described elsewhere in this document.

Definitions and Example Measures

Relapsing forms of multiple sclerosis — examples

DefinitionRelapsing forms of multiple sclerosis include clinically isolated syndrome, relapsing-remitting MS, and active secondary progressive MS.

Clinically isolated syndrome (CIS)First clinical presentation with inflammatory demyelination that may represent MS but does not yet meet diagnostic criteria.

Relapsing-remitting MS (RRMS)Disease course characterized by clearly defined relapses followed by periods of remission; most patients present with this pattern initially.

Active secondary progressive MS (active SPMS)Secondary progressive disease with evidence of active inflammatory activity (clinical relapses or MRI activity).

Examples of objective measures of benefit

MRI activity