Limited Coverage Drugs - Special Authority Criteria
| Generic Name / Strength / Form |
| glatiramer acetate |
| Criteria |
Approval Period |
Initial: As first- or second-line monotherapy for the treatment of relapsing-remitting MS diagnosed according to the current clinical criteria and magnetic resonance imaging (MRI) evidence, when prescribed by a neurologist from a designated MS clinic, for patients who meet ALL of the following criteria:
- Patient has had at least two (2) disabling attacks of MS in the previous two (2) years, AND
- Patient is ambulatory with or without aid (EDSS of 6.5 or less), AND
- Patient is 18 years of age or older.
|
One Year
|
| Renewal: As first-line monotherapy for the treatment of patients with relapsing-remitting MS, when prescribed by a neurologist from a designated MS clinic for patients who demonstrate continued therapeutic benefit outweighing any potential risks, as shown by relapse rate, EDSS, MRI scan, or overall clinical impression. |
One Year
|
| Change of Therapy: As second-line monotherapy for the treatment of patients with relapsing-remitting MS, when prescribed by a neurologist from a designated MS clinic, for patients who have experienced failure or intolerance to a previous disease modifying therapy. |
One Year |
Practitioner Exemptions
Neurologists specializing in MS whose primary place of practice is in a designated MS clinic have been invited to apply for individual specialist exemption from completing Special Authority forms, by entering into a Collaborative Prescribing Agreement (PDF 54K).
Special Notes
- The current clinical criteria for the diagnosis of MS are the McDonald criteria, as of October 26, 2010.
- An attack is defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 24 hours in the absence of fever, and preceded by stability for at least one (1) month.
Online Forms
5351 – Disease Modifying Drug Coverage for Multiple Sclerosis (PDF 550K)
Click on the link to complete a Special Authority request form.
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