Copaxone 20 mg/mL — Cigna

multiple sclerosis

Preferred products

Patient meets BOTH of the following (A and B):
A) Patient meets the standard Multiple Sclerosis – Glatiramer Products Prior Authorization Policy criteria; AND
B) Patient meets BOTH of the following (i and ii):
i. Patient meets ONE of the following (a or b):
a) Patient has been established on a glatiramer product for ≥ 120 days; OR
b) Patient meets BOTH of the following [(1) and (2)]:
(1) Patient has tried generic dimethyl fumarate delayed-release capsules [documentation required]; AND
(2) Patient has experienced inadequate efficacy or significant intolerance, according to the prescriber [documentation required];
ii. Patient meets BOTH of the following (a and b):
a) Patient has tried generic glatiramer injection [documentation required]; AND
b) Patient cannot continue to use generic glatiramer injection due to a formulation difference in inactive ingredient(s) [e.g., preservatives] between the brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required].

1 year