Copaxone 40 mg/mL — Medica
multiple sclerosis
Preferred products
- generic glatiramer injection
- generic dimethyl fumarate delayed-release capsules
Initial criteria
- Patient meets the standard Multiple Sclerosis – Glatiramer Products Prior Authorization Policy criteria
- AND one of the following:
- Patient has tried generic dimethyl fumarate delayed-release capsules (or Tecfidera) AND experienced inadequate efficacy or significant intolerance according to the prescriber
- OR patient has tried generic glatiramer injection AND Copaxone is being requested due to a formulation difference in inactive ingredient(s) (e.g., preservatives) between brand and generic which per the prescriber would result in a significant allergy or serious adverse reaction
Approval duration
1 year