Product Details

Plegridy

Peginterferon Beta-1A
63 mcg/0.5 mL & 94 mcg/0.5 mL
Liquid for Subcutaneous Injection
Starter Pack 63-mcg & 94-mcg Pre-Filled Pen (Preservative-Free)

DIN/PIN/NPN

09857557

Manufacturer

Biogen Idec Canada Inc.

Formulary Listing Date

2023-03-31  

Unit Price

1879.4900

Amount MOH Pays

1879.4900

Coverage Status

Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

L03AB13

Interchangeable Products

NO  

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Multiple Sclerosis Drugs

Peginterferon beta-1a

  • Brand(s): Plegridy
  • Dosage Form/Strength: 125mcg/0.5mL, 94mcg/0.5mL Injection, Starter Pack: 63mcg/0.5mL, 94mcg/0.5mL

For the treatment of Clinically Definite Multiple Sclerosis (CDMS)/Relapsing remitting multiple sclerosis (RRMS) in patients meeting the following criteria: 

Plegridy requests will be reviewed by external medical experts when the following information is provided: 

  • Details of the most recent neurological examination within the last ninety (90) days, including a description of any recent attacks (date and neurological findings) 

  • The patient has experienced at least two clinical attacks in his or her lifetime, including one clinical attack within the past 12 months preceding the EAP request; 

  • MRI findings as applicable 

  • The patient’s EDSS is less than or equal to 6.0 

Duration of Approval: 1 year 

Renewal requests for Plegridy can be submitted through the Telephone Request Service. Plegridy renewals will be considered for patients who have benefited from therapy. 

Patients must be stable (i.e., no relapses or attacks during the last year) and the patient’s EDSS must be less than or equal to 6.0

The physician must provide the following information: 

  • Description of the patient’s clinical course in the last year, including details of all attacks; 

  • Date and details of the most recent neurological examination (within the last 90 days); AND 

  • The patient’s most recent EDSS score.

*Renewal requests where patients have experienced more than one (1) clinical relapse in the past year will be considered on a case-by-case basis through an external review. 

As applicable, include information regarding the requesting physician’s specialty (e.g., is the physician a neurologist or a physician with specialized experience with multiple sclerosis (MS), the name of the MS clinic where the neurologist is based, or an MS consult note supporting the diagnosis as this information may reduce the turnaround times for assessment. 

Duration of Approval:
- First Renewal: 2 years
- Second and subsequent renewals: 5 years

EAP Drug Request Form:

Standard Form for EAP Drug Requests
Renewals of Multiple Sclerosis Drugs – Telephone Request Service (TRS) Drugs

Peginterferon beta-1a

  • Brand(s): Plegridy
  • Dosage Form/Strength: 125mcg/0.5mL, 94mcg/0.5mL Injection; Starter Pack: 63mcg/0.5mL, 94mcg/0.5mL

EAP will renew coverage of peginterferon beta-1a only for patients who have benefited from therapy and have an EDSS score ≤ 6. 

The prescriber must provide the following information: 

  • Description of the patient’s clinical course in the last year, including details of all attacks; 

  • Date and details of the most recent neurological examination (within the last 90 days); AND 

  • EDSS score 

Standard Approval Duration: 2 years, 5 years for 2nd and subsequent renewals

Renewals:
Renewal requests where patients have experienced more than 1 attack in the past year will be externally reviewed.

Product Monograph

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