Copaxone (glatiramer acetate subcutaneous injection [20 mg/mL and 40 mg/mL] - Teva, generic) — Cigna

Relapsing forms of multiple sclerosis including clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease in adults

Initial criteria

Patient has a relapsing form of multiple sclerosis; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Reauthorization criteria

Patient has a relapsing form of multiple sclerosis; AND
Patient has received glatiramer for ≥ 1 year; AND
Patient experienced a beneficial clinical response when assessed by at least one objective measure (e.g., stabilization or reduced worsening in disease activity by MRI, EDSS, NEDA-3/NEDA-4, FSIQ-RMS, relapse reduction, six-minute walk test improvement, MSFC score improvement, or attenuation of brain volume loss) OR patient experienced stabilization, slowed progression, or improvement in at least one symptom such as motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or pain/numbness/tingling sensation; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Approval duration

1 year