CurrentMass General Brigham Health PlanPolicy N/A

Tascenso (fingolimod) ODT prior authorization

This policy governs prior authorization requirements for Tascenso (fingolimod) ODT under the pharmacy benefit for Commercial/Exchange members of Mass General Brigham Health Plan, including initial and reauthorization criteria and quantity limits.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTascenso (fingolimod) ODT prior authorization

Policy CodePolicy N/A

Change TypeMaterial and non‑material revisions

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization under the pharmacy benefit and document neurologist involvement and, for reauthorization, evidence of disease stability or improvement.

SourceLink

POLICY UPDATE CHANGES

Removed minimum weight requirement to align with updated FDA approved package labeling.

Updated language for specialist prescribers.

Updated reauthorization criteria to require documentation of improvement or disease stability.

10 yrsminimum patient age for coverage

12 monthsapproval duration

2 tabs/dayquantity limit

90 daysnew-to-plan window

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Initial Therapy

Approval will be granted if the member meets all of the following criteria:

Initial approval criteria: Member is 10 years of age or older; Member has one of the following diagnoses: (a) Clinically isolated syndrome, (b) Relapsing‑remitting disease, (c) Active secondary progressive disease; Requested medication is prescribed by or in consultation with a neurologist; Member has had inadequate response, adverse reaction, or contraindication to fingolimod capsules.

All conditions must be met for approval.

Continuation of Therapy

Reauthorization (continuation of therapy) will be approved when ALL of the following are met:

Reauthorization criteria: Documentation the member is experiencing disease stability or improvement on the requested medication.

Meets for 12‑month reauthorization when provided.

Authorization may be granted for members who are new to the plan within the past 90 days and are currently receiving the requested medication, provided the product was not obtained as samples or through the manufacturer's patient assistance program. This continuity provision applies to members already on therapy at the time of enrollment and is intended to avoid interruption of clinically necessary treatment while a full prior authorization is completed.

When submitting a request under this provision, include documentation showing the member was actively receiving the medication within the 90‑day window prior to enrolling in the plan (for example, prior pharmacy fill records or a treating clinician’s note). Requests that do not meet the new‑to‑plan continuity criteria may be subject to denial and should instead follow the standard prior authorization pathway outlined in the policy.

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required under the pharmacy benefit; approval is granted when the member meets all listed criteria including age, qualifying diagnosis, neurologist prescribing/consult, and prior inadequate response to fingolimod capsules. Authorization may also be granted for members new to the plan within the past 90 days who are currently receiving treatment with the requested medication (excluding samples or manufacturer patient assistance programs).

Plan: Commercial/Exchange
Program Type: Prior Authorization
Benefit: Pharmacy Benefit
Effective: 2025-11-01

Step Therapy

No step therapy program applied in this policy.

Documentation Required

Reauthorization Documentation

For reauthorization, documentation that the member is experiencing disease stability or improvement on Tascenso (requested medication) is required. Requests for continuation of therapy will be approved only when such documentation is provided.

Continuation of Therapy: Documentation of disease stability or improvement is required for reauthorization.

Denial Risk

Criteria Non‑adherence

Requests that do not meet the listed criteria will be denied. Criteria include: age ≥10 years, a qualifying multiple sclerosis diagnosis (clinically isolated syndrome, relapsing‑remitting disease, or active secondary progressive disease), prescription by or consultation with a neurologist, and prior inadequate response, adverse reaction, or contraindication to fingolimod capsules. Approval may also be considered for members new to the plan within 90 days who are already receiving the medication (excluding samples or manufacturer assistance).

Clinical Background

Tascenso (fingolimod) orally disintegrating tablet is a sphingosine 1‑phosphate receptor modulator indicated for the treatment of relapsing forms of multiple sclerosis in patients aged 10 years and older. The policy aligns authorization requirements with FDA‑approved labeling and includes provisions to ensure continuity of care for members newly enrolled in the plan.

Prescribing should be by or in consultation with a neurologist and authorization decisions consider prior treatment history with fingolimod capsules; for members already receiving Tascenso at enrollment, the 90‑day new‑to‑plan continuity window permits interim authorization while full documentation is provided.

Definitions and Indications

Relapsing forms of multiple sclerosis — policy definition

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

Indication age rangeApplies to pediatric and adult patients 10 years of age and older.

Authorization linkageThese diagnoses are the qualifying indications for prior authorization of Tascenso (fingolimod) ODT under this policy.

Prescriber requirementRequested medication must be prescribed by or in consultation with a neurologist.

Prior therapy considerationMember must have had inadequate response, adverse reaction, or contraindication to fingolimod capsules to meet initial approval criteria.