Copaxone (glatiramer acetate) — Highmark

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