Copaxone (glatiramer acetate) — Highmark
multiple sclerosis (ICD-10: G35) – clinically isolated syndrome
Preferred products
- plan-preferred Glatopa
- glatiramer
Initial criteria
- age ≥ 18 years
- member has a diagnosis of multiple sclerosis (ICD-10: G35) classified as clinically isolated syndrome OR relapsing-remitting disease OR active secondary progressive disease
- IF request is for brand Copaxone 20 mg THEN member has experienced therapeutic failure or intolerance to ONE of the following: glatiramer OR plan-preferred Glatopa
Reauthorization criteria
- prescriber attests member has experienced therapeutic response defined as disease stability OR disease improvement OR delayed disease progression
- IF request is for brand Copaxone 20 mg THEN member has experienced therapeutic failure or intolerance to ONE of the following: glatiramer OR plan-preferred Glatopa
Approval duration
12 months