Copaxone (glatiramer) — Blue Cross Blue Shield of Montana

Preferred products

• Avonex (interferon β-1a)
• Betaseron (interferon β-1b)
• dimethyl fumarate
• glatiramer
• Glatopa (glatiramer)
• Kesimpta (ofatumumab)
• Mayzent (siponimod)
• Rebif (interferon β-1a)
• teriflunomide
• Zeposia (ozanimod)

Initial criteria

• ONE of the following: (A) The requested agent is eligible for continuation of therapy AND (1) 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 (B) BOTH of the following: (1) the patient has a diagnosis of a relapsing form of MS AND ALL of the following:
• ONE of the following: The requested agent is a preferred agent OR The requested agent is a non-preferred agent AND ONE of the following: (1) the prescriber states the patient is currently being treated with the requested agent AND the patient is currently stable on the requested agent [chart notes required];
• OR for patients age ≤ 17 years: ONE of the following: (A) requested agent is Gilenya 0.25 mg or Tascenso ODT 0.25 mg (no equipotent generic strength) OR (B) patient has tried and had inadequate response to generic fingolimod OR (C) generic fingolimod discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event OR (D) intolerance/hypersensitivity to generic fingolimod OR (E) FDA labeled contraindication to generic fingolimod OR (F) generic fingolimod expected ineffective / causes barrier to adherence / worsens condition / decreases function / causes adverse reaction or harm OR (G) not in best interest based on medical necessity OR (H) tried another agent in same class and discontinued due to inefficacy/adverse event OR (I) if requested agent is Tascenso ODT 0.5 mg, support for use (e.g., swallowing difficulties).
• For patients age ≥ 18 years: BOTH of the following: (A) ONE of the following: (1) tried and had inadequate response to TWO preferred agents FDA labeled for MS OR (2) TWO preferred agents discontinued due to lack of efficacy/effectiveness/adverse event OR (3) intolerance/hypersensitivity to TWO preferred agents OR (4) FDA labeled contraindication to ALL preferred agents OR (5) TWO preferred agents expected ineffective / cause adherence barrier / worsen condition / decrease function / cause harm OR (6) TWO preferred agents not in best interest based on medical necessity OR (7) tried another prescription drug in same class/mechanism as TWO preferred agents and discontinued due to lack of efficacy/effectiveness/adverse event AND (B) if requested agent is Tascenso ODT 0.5 mg, ONE of the specified fingolimod conditions (inadequate response, discontinued due to lack of efficacy/adverse event, intolerance, contraindication, expected ineffective, not in best interest, tried other agent, or support for use such as swallowing difficulty).
• OR Patient has highly active MS disease activity with ≥ 2 relapses in the previous year [medical records required].

Reauthorization criteria

• Patient previously approved for requested agent through plan's prior authorization AND
• Patient has had clinical benefit with the requested agent AND
• Complete CBC with differential including lymphocyte count performed AND lymphocyte count ≥ 800 cells/microliter AND
• Prescriber is specialist (neurologist) or has consulted with specialist AND
• ONE of the following: (A) will NOT use requested agent in combination with another disease modifying agent OR (B) support exists for combination use (e.g., relapse between cycles) AND
• Patient has no FDA labeled contraindications to the requested agent AND
• It has been ≥ 35 weeks and ≤ 67 weeks since last dose AND
• Prescriber has documented number of treatment courses completed AND patient has NOT completed 2 courses (each course = 2 cycles of 4-5 days each) AND
• Requested dose does NOT exceed maximum FDA labeled dose for patient weight.

Approval duration

12 months (BCBSIL/BCBSMT/BCBSTX); 3 months (other plans)