Subject: Mayzent 2973-A SGM P2021
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and compendial uses are considered a
covered benefit provided that all the approval criteria are met and the member has no
exclusions to the prescribed therapy.
FDA-Approved Indications
Mayzent is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include
clinically isolated syndrome, relapsing-remitting disease and active secondary progressive
disease, in adults.
All other indications are considered experimental/investigational and not medically necessary.
II. CRITERIA FOR INITIAL APPROVAL
A. Relapsing forms of multiple sclerosis
Authorization of 12 months may be granted to members who have been diagnosed with a
relapsing form of multiple sclerosis (including relapsing-remitting and secondary progressive
disease for those who continue to experience relapse).
B. Clinically isolated syndrome
Authorization of 12 months may be granted to members for the treatment of clinically
isolated syndrome.
III. CONTINUATION OF THERAPY
For all indications: Authorization of 12 months may be granted for members who are
experiencing disease stability or improvement while receiving Mayzent.
IV. OTHER CRITERIA
Members will not use Mayzent concomitantly with other disease modifying multiple sclerosis
agents (Note: Ampyra and Nuedexta are not disease modifying).
Place of Service:
Outpatient
The above policy is based on the following references:
- Mayzent [package insert]. East Hanover, NJ: Novaritis; January 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
February 14, 2022
