CurrentCignaPolicy N/A

Multiple Sclerosis (Injectable - Beta Interferon) - Plegridy Prior Authorization Policy

This Cigna prior authorization policy defines medical necessity criteria, duration of approval, and exclusions for Plegridy (peginterferon beta-1a) for treatment of relapsing forms of multiple sclerosis in adults, and requires prescribing by or in consultation with a neurology specialist.

Policy Summary

PayerCigna

PolicyMultiple Sclerosis (Injectable - Beta Interferon) - Plegridy Prior Authorization Policy

Policy CodePolicy N/A

Change TypeClarified (administrative/appendix updates)

Effective Date

Next Review Date

Key ActionObtain prior authorization and ensure Plegridy is prescribed by or in consultation with a neurologist or MS specialist; approvals are provided for 1 year when criteria are met.

POLICY UPDATE CHANGES

07/23/2025 listed as Early Annual Revision, Review Date; policy name changed historically to add 'Injectable - Beta Interferon' and Appendix modified over time.

1Approval duration (years)

2Main coverage pathways

2Primary exclusion categories

Coverage Summary

Scope: This Cigna prior authorization policy defines medical necessity criteria, duration of approval, and exclusions for Plegridy (peginterferon beta-1a) for treatment of relapsing forms of multiple sclerosis in adults and requires prescribing by or in consultation with a neurology specialist.

Key Details

Policy subjectPlegridy (peginterferon beta-1a) prior authorization for relapsing multiple sclerosis

DrugPlegridy / peginterferon beta-1a

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

Approval duration1 year

Prescriber requirementMust be prescribed by or in consultation with a neurologist or physician who specializes in MS

Medical-Necessity Criteria

FDA-Approved Indication

Plegridy is covered as medically necessary for Multiple Sclerosis when ONE of the following is met:

ANY of the following

A) Initial Therapy - Approve for 1 year if ALL of the following are met
- Patient has a relapsing form of multiple sclerosis
  Examples include clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease.
- Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis
B) Currently Receiving Plegridy ≥ 1 Year - Approve for 1 year if ALL of the following are met
- Patient has a relapsing form of multiple sclerosis
  Examples include clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease.
- ONE of
  - Patient experienced a beneficial clinical response when assessed by at least one objective measure
    Examples include stabilization or reduced worsening in MRI (absence or decrease in gadolinium enhancing lesions; decrease in number of new or enlarging T2 lesions); stabilization or reduced worsening on EDSS; achievement of NEDA-3 or NEDA-4; improvement on FSIQ-RMS scale; reduction or absence of relapses; improvement or maintenance on 6-minute walk test or 12-Item MS Walking Scale; improvement on MSFC score; attenuation of brain volume loss.
  - 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
- Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Not Medically Necessary / Exclusions

Conditions Not Covered

Plegridy is considered not medically necessary for ANY other uses including but not limited to:

ALL of the following

Concurrent use with other disease-modifying agents used for multiple sclerosis
Examples provided in Appendix; combination not indicated and additional data required.
Non-relapsing forms of multiple sclerosis
Efficacy not established for non-relapsing forms (example: primary progressive multiple sclerosis).

Practical callout: Claims for Plegridy for concurrent use with other disease-modifying MS agents or for non-relapsing forms of multiple sclerosis (e.g., primary progressive MS) are considered not medically necessary and may be denied.

Provider Actions

Prior Authorization

Prior authorization required

Prior Authorization is recommended/required for prescription benefit coverage of Plegridy; approvals provided for the durations specified (1 year).

Approval duration: 1 year

Documentation Required

Specialist prescribing/consultation requirement

Medication must be prescribed by or in consultation with a neurologist or physician who specializes in the treatment of multiple sclerosis for both initial therapy and continuation.

Denial Risk

Denial risk for non-covered uses

Claims for Plegridy for concurrent use with other disease-modifying MS agents or for non-relapsing forms of multiple sclerosis (e.g., primary progressive MS) are considered not medically necessary and may be denied.

Background, Evidence & Definitions

Plegridy (peginterferon beta-1a) is an interferon beta product FDA-indicated for the treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease in adults.

The policy situates Plegridy among other disease-modifying therapies for MS and references consensus guidance on use of disease-modifying therapies.

MS is a chronic, inflammatory, demyelinating, autoimmune disease with heterogeneous disease courses; disability is commonly graded using the Expanded Disability Status Scale (EDSS) and disease course categories include clinically isolated syndrome, relapsing remitting MS, secondary progressive MS, and primary progressive MS.

Source	Citation
Prescribing Information
Plegridy prescribing information, Biogen; July 2023
Guidance
MS Coalition consensus paper, September 2019

Relapsing forms of multiple sclerosis: Includes clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease.

Revision History

07/23/2025Early Annual Revision, Review DateLatest

Early Annual Revision, Review Date; policy name changed historically to add "Injectable - Beta Interferon" and Appendix modified over time.

08/10/2023Update, Summary of Changes

No criteria changes.