glatiramer — Medical Mutual

Preferred products

• generic glatiramer acetate
• Glatopa

Initial criteria

• Patient does NOT have a non-relapsing form of multiple sclerosis (MS) [e.g., primary progressive MS]
• Patient will NOT be using concurrently with other disease-modifying agents used for multiple sclerosis
• Patient is age ≥ 18 years
• Agent is prescribed by, or in consultation with, a neurologist or a physician who specializes in the treatment of MS
• If brand Copaxone is prescribed: Patient has previously failed or is intolerant to generic glatiramer acetate 20 mg/mL or 40 mg/mL AND Brand Copaxone is being requested due to a formulation difference in inactive ingredient(s) [e.g., preservatives] between the brand and the bioequivalent generic product which, per the prescribing physician, has or would result in a significant allergy or serious adverse reaction

Reauthorization criteria

• Patient is age ≥ 18 years
• Patient has a relapsing form of MS to include clinically isolated syndrome, relapsing-remitting disease, or active secondary progressive disease
• Agent is prescribed by, or in consultation with, a neurologist or a physician who specializes in the treatment of MS
• Patient has had beneficial response to the requested medication
• Patient has no contraindications to the requested medication
• If brand Copaxone is prescribed: Patient has previously failed or is intolerant to generic glatiramer acetate 20 mg/mL or 40 mg/mL AND Brand Copaxone is being requested due to a formulation difference in inactive ingredient(s) [e.g., preservatives] between the brand and the bioequivalent generic product which, per the prescribing physician, has or would result in a significant allergy or serious adverse reaction

Approval duration

365 days