Plegridy — Medica
relapsing forms of multiple sclerosis (clinically isolated syndrome, relapsing remitting disease, or 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.
Reauthorization criteria
- 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 as evaluated by MRI, stabilization or reduced worsening on EDSS score, achievement of NEDA-3 or NEDA-4, improvement on FSIQ-RMS, reduction or absence of relapses, improvement or maintenance on six-minute walk test or 12-Item MS Walking Scale, improvement on MSFC score, or attenuation of brain volume loss); OR
- Patient experienced stabilization, slowed progression, or improvement in at least one symptom such as motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or 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.
Approval duration
1 year