glatiramer (Copaxone®, Glatopa®)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Relapsing remitting multiple sclerosis (RRMS)
  • Secondary progressive multiple sclerosis (SPMS)

Patients must meet the following criteria for the indications above:

  • Not to be used in combination with each other or any other disease modifying therapy including natalizumab (Tysabri), mitoxantrone (Novantrone), alemtuzumab or fingolimod (Gilenya).
  • Use of glatiramer 20mg daily is WHA’s preferred agent and use of the 40mg three times weekly requires medical justification.  Glatopa is available at the Tier 2 copayment.

This medication is not approvable for for the following condition(s):

  • Any condition not listed above does not meet WHA criteria for approval

Dosing:

  • glatiramer  -  20 mg SC daily

Approval Period

  • Initial approval for one year
  • Renew for one year if patient has clinical response

                                                                     

Last review date: July 20, 2016

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