Product Details
Copaxone
Glatiramer Acetate20 mg/mL
Solution for Subcutaneous Injection
Single-Use 1-mL Prefilled Syringe (Preservative-Free)
DIN/PIN/NPN
02245619
Manufacturer
Teva Canada Innovation.
Formulary Listing Date
2023-04-28
Unit Price
50.6522
Amount MOH Pays
27.8587
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
L03AX13
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
02245619 | Copaxone | 50.6522 | 27.8587 |
02541440 | Glatiramer Acetate Injection | 27.8587 | 27.8587 |
LU Clinical Criteria
LU Code | Auth. Period | Clinical Criteria |
---|---|---|
691 | 1 year | As monotherapy for the treatment of patients with relapsing remitting multiple sclerosis (RRMS) meeting ALL the following criteria:
Note: Transition from another Disease Modifying therapy (DMT) is permitted in those who are deemed to have met the above criteria prior to initiation of the other DMT and if glatiramer acetate is used as monotherapy. |
692 | 1 year | As monotherapy for the treatment of patients who have experienced a single demyelinating event/ Clinically Isolated Syndrome (CIS) meeting ALL the following criteria:
Note: Transition from another Disease Modifying therapy (DMT) is permitted in those who are deemed to have met the above criteria prior to initiation of the other DMT and if glatiramer acetate is used as monotherapy. |
693 | 1 year | Renewal of therapy for patients diagnosed with relapsing remitting multiple sclerosis (RRMS) or a single demyelinating event /Clinically Isolated Syndrome (CIS) who meet ALL the following criteria:
|