glatiramer acetate — Medica

Initial criteria

• Patient has a relapsing form of multiple sclerosis (examples include clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease); AND
• Medication is prescribed by or in consultation with a neurologist or physician who specializes in the treatment of multiple sclerosis

Reauthorization criteria

• Patient has a relapsing form of multiple sclerosis (examples include clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease); AND
• Patient has been receiving 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 on MRI, stabilization or reduced worsening on Expanded Disability Status Scale, achievement of NEDA criteria, improvement on the fatigue symptom and impact questionnaire-relapsing multiple sclerosis scale, reduction or absence of relapses, improvement or maintenance on walking tests, improvement on MS Functional Composite score, or attenuation of brain volume loss) OR 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; AND
• Medication is prescribed by or in consultation with a neurologist or physician who specializes in the treatment of multiple sclerosis

Approval duration

1 year