Copaxone — Blue Cross Blue Shield of Alabama
Multiple sclerosis
Preferred products
- Avonex
- Betaseron
- dimethyl fumarate
- fingolimod
- glatiramer
- Glatopa
- Kesimpta
- Mavenclad
- Mayzent
- Plegridy
- Rebif
- teriflunomide
- Vumerity
Initial criteria
- ONE of the following:
- • The requested agent is eligible for continuation of therapy AND ONE of the following:
- – The patient has been treated with the requested agent within the past 90 days OR
- – The prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed
- OR
- • The requested agent is a preferred agent OR
- • The requested agent is a non-preferred agent AND ONE of the following:
- – The patient’s medication history includes the use of TWO preferred agents within the past 365 days OR
- – The patient has an intolerance or hypersensitivity to TWO preferred agents OR
- – The patient has an FDA labeled contraindication to ALL preferred agents
- AND
- If the requested agent is a brand agent with a generic equivalent, ONE of the following applies:
- – The patient’s medication history includes use of the generic equivalent OR
- – The patient has an intolerance or hypersensitivity to the generic equivalent agent that is NOT expected to occur with the requested agent OR
- – The patient has an FDA labeled contraindication to the generic equivalent agent that is NOT expected to occur with the requested agent
- AND
- The patient will NOT be taking an additional disease modifying agent for the requested indication
Reauthorization criteria
- Continuation of therapy criteria: eligible if patient has been treated with the requested agent within the past 90 days or prescriber states recent use and risk if therapy changed.
Approval duration
12 months