Prior Authorization : Preferred Drug List

Multiple Scleroris Agents, Other

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Glatopa

PA requests for Glatopa must be completed, signed, and dated by the prescriber. PA requests for Glatopa must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for Glatopa may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

For information about general ForwardHealth PA policy for drugs that require PA approval, prescribers and pharmacy providers may refer to the Standard Pharmacy Policy for Covered and Noncovered Drugs topic. Providers may also refer to this topic for information about what may not be considered criteria to support the need for the drug.

Clinical Criteria for Glatopa

The prescriber must submit detailed clinical justification for prescribing Glatopa instead of the preferred MS agents Copaxone 20 mg and Copaxone 40 mg. This clinical information must document why the member cannot use Copaxone 20 mg and Copaxone 40 mg, including why it is medically necessary that the member receive Glatopa instead of Copaxone 20 mg and Copaxone 40 mg.

Supporting clinical information and a copy of the member's current medical records must be submitted with all PA requests for Glatopa. The supporting clinical information and medical records must document the following:

• The member's medical condition being treated
• Details regarding previous medication use
• The member's current treatment plan

Initial and Renewal PA Requests for Glatopa

If the clinical criteria for Glatopa are met, initial PA requests may be approved for up to 183 days. Renewal PA requests may be approved for up to 365 days.

Renewal PA requests for Glatopa must include copies of the member's current medical records demonstrating that the member's MS is stable and well-controlled without having disease-progressing symptoms.

All renewal PA requests for Glatopa require the member to be adherent with the prescribed treatment regimen.