Plegridy (peginterferon beta-1a subcutaneous or intramuscular injection - Biogen) — Cigna

Relapsing forms of multiple sclerosis (clinically isolated syndrome, relapsing remitting disease, active secondary progressive disease)

Initial criteria

Patient has a relapsing form of multiple sclerosis; AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Patient has a relapsing form of multiple sclerosis; AND
Patient experienced a beneficial clinical response when assessed by at least one objective measure (e.g., stabilization or reduced worsening in disease activity on MRI, EDSS, NEDA-3 or NEDA-4, FSIQ-RMS scale, relapse rate, walking tests, MSFC score, or attenuation of brain volume loss) OR patient experienced stabilization, slowed progression, or improvement in at least one symptom (motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, pain/numbness/tingling sensation); AND
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

1 year