glatiramer (Copaxone®, Glatopa®)
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
- glatiramer - 20 mg SC daily
- Initial approval for one year
- Renew for one year if patient has clinical response
Last review date: July 20, 2016