Plegridy (peginterferon beta-1a) — Medical Mutual

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

Initial criteria

Patient does NOT have non-relapsing forms of multiple sclerosis (e.g., primary progressive MS); AND
Patient will NOT use concurrently with other disease-modifying agents used for multiple sclerosis; AND
Patient is age ≥ 18 years; AND
The agent is prescribed by, or in consultation with, a neurologist or a physician who specializes in the treatment of multiple sclerosis; AND
Dosage and administration are consistent with U.S. Food and Drug Administration approved label; AND
Patient has previously failed or is intolerant to generic glatiramer acetate 20mg/mL or 40mg/mL according to the prescribing physician (exception: patients who already tried and cannot take brand Copaxone/Glatopa are not required to re-try generic glatiramer acetate); AND
Site of care medical necessity criteria are met

Patient does NOT have non-relapsing forms of multiple sclerosis; AND
Patient will NOT use concurrently with other disease-modifying agents for multiple sclerosis; AND
Patient is age ≥ 18 years; AND
The agent is prescribed by, or in consultation with, a neurologist or a physician who specializes in the treatment of multiple sclerosis; AND
Patient has had beneficial response to the requested medication; AND
The patient meets ONE of the following: has been established on the requested medication for ≥ 120 days OR has previously failed or is intolerant to generic glatiramer acetate 20mg/mL or 40mg/mL according to the prescribing physician (exception: if patient has already tried and cannot take brand Copaxone/Glatopa, not required to re-try generic glatiramer acetate); AND
Dosage and administration are consistent with FDA-approved label; AND
Site of care medical necessity criteria are met

365 days