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


  • Dosing schedule depends on the product strength that is selected.
    • 20 mg/ml: 20 mg SC daily OR
    • 40 mg/ml: 40 mg SC three times per week (at least 48 hours apart)

Approval Period

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


Last review date: January 3, 2020

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