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Copaxone — Blue Cross Blue Shield of New Mexico

Relapsing Remitting Multiple Sclerosis (RRMS)

Preferred products

  • teriflunomide
  • Glatopa
  • glatiramer
  • fingolimod
  • dimethyl fumarate

Initial criteria

  • Patient has ≥1 gadolinium enhancing lesion on MRI OR significant increase in T2 lesion load compared with previous MRI OR has been treated with at least 3 multiple sclerosis agents from different drug classes (medical records including chart notes required).
  • If requested agent is Aubagio (teriflunomide), prescriber has obtained transaminase and bilirubin levels within 6 months prior to initiating treatment.
  • If requested agent is Gilenya (fingolimod) or Tascenso ODT (fingolimod), prescriber has performed an electrocardiogram within 6 months prior to initiating treatment.
  • If patient has another FDA approved indication for requested agent and route, patient’s age is within FDA labeling OR supported for use for patient’s age for that indication.
  • If the requested agent is a brand product with a corresponding generic, then ONE of the following applies: A. Patient is currently treated and stable on requested agent [chart notes required] OR B. Patient has intolerance or hypersensitivity to corresponding generic not expected to occur with requested agent [chart notes required] OR C. Patient has an FDA labeled contraindication to corresponding generic not expected to occur with requested agent [chart notes required] OR D. The corresponding generic was discontinued due to lack of efficacy/effectiveness/adverse event [chart notes required] OR E. The corresponding generic is expected to be ineffective or cause adherence barriers/comorbid worsening/function decrease/adverse reaction [chart notes required] OR F. Corresponding generic is not in best interest based on medical necessity [chart notes required] OR G. Patient has tried another drug in same class or mechanism and discontinued due to lack of efficacy/effectiveness/adverse event [chart notes required] OR H. Support exists for use of requested agent over generic.
  • Prescriber is a specialist in neurology or has consulted with a neurologist.
  • ONE of the following combination conditions applies: A. Patient will NOT use the requested agent in combination with another disease modifying agent (DMA) for the requested indication OR B. Patient will use the requested agent in combination with Mavenclad (cladribine) AND there is support for such use (e.g., relapse between cycles of Mavenclad).
  • Patient does NOT have any FDA labeled contraindications to the requested agent.
  • For BCBS MT Fully Insured or MT HIM members <18 years old: indication supported in TWO peer-reviewed studies as generally safe and effective AND age bracket support met AND no FDA labeled contraindications.
  • For Ohio Fully Insured or HIM Shop members: member resides in Ohio, plan type verified, no FDA labeled contraindications, and ONE of the following applies: 1. Another FDA labeled indication for agent OR 2. Indication supported in compendia OR 3. Two peer-reviewed studies support proposed use as generally safe and effective (not case studies). Allowed compendia: DrugDex (level 1, 2A, or 2B), AHFS-DI (supportive narrative), NCCN (1 or 2A for oncology), Clinical Pharmacology/AHFS-DI/LexiDrugs (supportive narrative as applicable).

Reauthorization criteria

  • Patient previously approved for requested agent through plan prior authorization AND
  • If the requested agent is a brand product with a corresponding generic, then ONE of the following applies: A. Patient currently treated and stable on requested agent [chart notes required] OR B. Patient has intolerance/hypersensitivity to generic not expected with requested agent [chart notes required] OR C. Patient has FDA labeled contraindication to generic not expected with requested agent [chart notes required] OR D. Generic discontinued for lack of efficacy/effectiveness/adverse event [chart notes required] OR E. Generic expected ineffective or not tolerated or causes adherence/comorbid/function issues/adverse reaction [chart notes required] OR F. Generic not in best interest based on medical necessity [chart notes required] OR G. Patient has tried another same-class or mechanism drug discontinued due to lack of efficacy/effectiveness/adverse event [chart notes required] OR H. Support exists for use of requested agent over the corresponding generic.
  • Patient has had clinical benefit with requested agent.
  • Prescriber is a neurologist or consulted with one.
  • ONE of the following combination conditions applies: A. Patient will NOT use requested agent in combination with another DMA OR B. Patient will use requested agent in combination with Mavenclad (cladribine) AND supporting information exists (e.g., relapse between Mavenclad cycles).
  • Patient does NOT have any FDA labeled contraindications to requested agent.

Approval duration

12 months