Prior Authorization and Quantity Limit Criteria for Approval

Mavenclad will be approved when ALL of the following are met:

1. The patient has an FDA labeled indication for the requested medication
   AND
2. The patient will NOT be using the requested medication in combination with another disease modifying agent (DMA) for the requested indication
   AND
3. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND
4. The requested dose is within FDA labeled dosing for the requested indication
   AND
5. The total cumulative duration of treatment with Mavenclad (cladribine) has not exceeded 4 treatment cycles

Length of Approval: No prior Mavenclad use - approve 2 years;

Prior Mavenclad use - approve remainder of 2 years of total cumulative therapy