Download the latest Prescription and Service Request (PSR) Form for your practice now.

Download

A TRUSTED APPROACH TO PATIENT ADHERENCE AND SUPPORT

For more than 20 years, Teva’s Shared Solutions® has partnered with your practice and your patients, helping them start and stay committed to therapy.

Prescription and Service Request (PSR) Form

Submitting up-to-date COPAXONE® Prescription & Service Request Forms is the first step for your patients to receive adherence and educational support from Teva's Shared Solutions® during their COPAXONE® therapy.

  • When prescribing COPAXONE®, both new prescriptions and refills, download the latest Prescription & Service Request Form.
  • Your patient (or authorized representative) must read, sign, and date the Patient Authorization section.
  • In the Prescriber Signature section, indicate Dispense as Written (DAW) to help ensure your patients receive COPAXONE® as prescribed, rather than a generic option, from the pharmacy.
  • Submit completed forms via fax to 1-800-775-5834.

Call Teva's Shared Solutions® at 1-800-887-8100 to request Prescription and Service Request Form tear pads and other patient resources.

SEE AVAILABLE RESOURCES

Letter of Medical Necessity

A template of a letter payers may require to establish medical necessity.

DOWNLOAD TEMPLATE

Appeals Letter

A template of a letter payers may require to appeal a denial of coverage.

DOWNLOAD TEMPLATE

Patient training and adherence support

Compassionate, professional nurse support helps patients stay compliant throughout their therapy experience.

  • Injection training: Teva-trained nurses provide free, in-home, 1-on-1 injection training when starting or switching to COPAXONE®. Sessions address proper injection technique, injection site rotation, and tips to help manage ISRs and maintain healthy skin.
  • Learn more on the COPAXONE® patient site.
  • Phone support: Teva nurses are available for personalized phone guidance and support. COPAXONE® patients may speak to a nurse by calling 1-800-887-8100.
  • COPAXONE iTracker® 2.0: The improved mobile app for Apple® and Android helps patients track their injections, manage injection site rotation, and stay committed to therapy. Features include:
    • Injection calendar with personalized reminders
    • Injection site rotation tracking and guidance
    • Journal for recording and organizing injection notes
    • Direct connection to Teva’s Shared Solutions® phone support
    • Video injection tutorials and helpful tips
  • Learn more on the COPAXONE® patient site, and suggest your patients download COPAXONE iTracker® 2.0 from the App Store® or Google Play.
  • autoject®2 for glass syringe: Available free with a prescription through Teva's Shared Solutions®. This device hides the needle and delivers therapy with a light button press.

Building strong MS community connections

Teva maintains educational and community opportunities, helping your patients learn from MS experts and draw inspiration from the stories of others living with relapsing MS.

  • Lift MS®: A blog and Facebook community devoted to supporting MS patients and their Care Partners with advice from Patient Advocates and MS specialists.

For questions or to request any of Teva’s Shared Solutions® services, have your patients call 1-800-887-8100 or visit COPAXONE.com.

Indication

COPAXONE® is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

Important Safety Information

Contraindication: COPAXONE® is contraindicated in patients with known hypersensitivity to glatiramer acetate or mannitol.

Immediate Post-Injection Reaction: Approximately 16% of patients exposed to COPAXONE® 20 mg per mL compared to 4% of those on placebo, and approximately 2% of patients exposed to COPAXONE® 40 mg per mL compared to none on placebo experienced a constellation of symptoms that may occur immediately (within seconds to minutes, with the majority of symptoms observed within 1 hour) after injection and included at least 2 of the following:  flushing, chest pain, palpitations, tachycardia, anxiety, dyspnea, throat constriction, and urticaria. In general, these symptoms have their onset several months after the initiation of treatment, although they may occur earlier, and a given patient may experience 1 or several episodes of these symptoms. Typically, the symptoms were transient and self-limited and did not require treatment; however, there have been reports of patients with similar symptoms who received emergency medical care.

Chest Pain: Transient chest pain was noted in 13% of COPAXONE® 20 mg per mL patients compared to 6% of placebo patients, and approximately 2% of COPAXONE® 40 mg per mL patients compared to 1% on placebo. While some episodes of chest pain occurred in the context of the Immediate Post-Injection Reaction described above, many did not. The temporal relationship of this chest pain to an injection was not always known. The pain was usually transient, often unassociated with other symptoms, and appeared to have no clinical sequelae. Some patients experienced more than 1 such episode, and episodes usually began at least 1 month after the initiation of treatment.

Lipoatrophy and Skin Necrosis: At injection sites, localized lipoatrophy and, rarely, injection site skin necrosis may occur. Lipoatrophy may occur at various times after treatment onset (sometimes after several months) and is thought to be permanent. There is no known therapy for lipoatrophy.

Potential Effects on Immune Response: Because COPAXONE® can modify immune response, it may interfere with immune functions.  For example, treatment with COPAXONE® may interfere with recognition of foreign antigens in a way that would undermine the body’s tumor surveillance and its defenses against infection. There is no evidence that COPAXONE® does this, but there has not been a systematic evaluation of this risk.

Hepatic Injury: Cases of hepatic injury, some severe, including liver failure and hepatitis with jaundice, have been reported with COPAXONE®. Hepatic injury has occurred from days to years after initiating treatment with COPAXONE®­­­. If signs or symptoms of liver dysfunction occur, consider discontinuation of COPAXONE®.

Common Adverse Reactions: In controlled studies of COPAXONE® 20 mg per mL, the most common adverse reactions with COPAXONE® vs placebo were injection site reactions (ISRs), such as erythema (43% vs 10%); vasodilatation (20% vs 5%); rash (19% vs 11%); dyspnea (14% vs 4%); and chest pain (13% vs 6%). 

In a controlled study of COPAXONE® 40 mg per mL, the most common adverse reactions with COPAXONE® vs placebo were ISRs, such as erythema (22% vs 2%). 

ISRs were one of the most common adverse reactions leading to discontinuation of COPAXONE®. ISRs, such as erythema, pain, pruritus, mass, edema, hypersensitivity, fibrosis, and atrophy, occurred at a higher rate with COPAXONE® than placebo.

Please see full Prescribing Information for COPAXONE®.

Injections for 3-times-a-week COPAXONE® 40 mg must be at least 48 hours apart.

You are about to leave COPAXONEHCP.com and enter a website operated by a third party.

Would you like to continue?