Copaxone — CareFirst (Caremark)
Relapsing forms of multiple sclerosis (including relapsing-remitting disease and active secondary progressive disease) in adults
Initial criteria
- Medication must be prescribed by or in consultation with a neurologist
- Member has been diagnosed with a relapsing form of multiple sclerosis (including relapsing-remitting and secondary progressive disease for those who continue to experience relapse) OR has clinically isolated syndrome of multiple sclerosis
- Member will not use Copaxone, Glatopa, or glatiramer acetate concomitantly with other disease modifying multiple sclerosis agents (Ampyra and Nuedexta are not disease modifying)
Reauthorization criteria
- Member is experiencing disease stability or improvement while receiving Copaxone, Glatopa, or glatiramer acetate
Approval duration
12 months