PLEGRIDY Copay Program

Eligible commercially insured patients may lower their out-of-pocket costs to as low as $0.

During participation in the program, assistance provided by Biogen will not exceed an individual annual cap, which is based on certain factors, including but not limited to, insurance coverage, claim details, and/or participation in other insurance plan-sponsored programs. Once this cap is reached, you will be responsible for paying 100% of your total copay amount. By completing this form, you will be screened for eligibility in the PLEGRIDY Copay Program.

Federal and state laws and other factors may prevent or otherwise restrict eligibility. People covered by Medicare, Medicaid, Veterans Affairs (VA), the Department of Defense (DoD), or any other federal plans are not eligible to enroll. You are eligible to enroll in the PLEGRIDY Copay Program for as long as it is offered and you are treated with this Biogen medication, provided that you meet the eligibility criteria.

;

Patient Eligibility

  • 1
  • 2
  • 3
  • 4

Please answer all questions and click "SUBMIT" to continue.

Please provide State.

*TRICARE® is a registered trademark of the Department of Defense; Defense Health Agency. All rights reserved.

Patient Information

  • 1
  • 2
  • 3
  • 4

Please answer all questions and click "SUBMIT" to continue.

Please provide First Name.
Please provide Last Name.
Please provide Date of Birth.
Please provide Gender.
Please provide Address.
Please provide City.
Please provide State.
Please provide Zip Code.
Please provide Patient Home Phone Number.
Please provide Patient Cell Phone Number.
Please enter a valid email address.
Please select a response.

Your registration is almost finished!

  • 1
  • 2
  • 3
  • 4

In order to allow Biogen to provide you with support services,
please complete the patient authorization below.

I. Authorization to Share Health Information

I understand that I have certain rights related to the collection, use, and disclosure of [my/my child’s] medical and health information. This information is called “protected health information” (PHI) and includes demographic information (such as sex, race, date of birth, etc.), the results of physical examinations, clinical tests, blood tests, X-rays, and other diagnostic medical procedures that may be included in [my/my child’s] medical records. Biogen will not use [my/my child’s] PHI without my consent.

By signing this Authorization, I authorize [my/my child’s] healthcare provider, [my/my child’s] health insurance company and [my/my child’s] pharmacy providers (“Healthcare Entities”) to disclose to Biogen, and companies working with Biogen (collectively, “Biogen”), health information relating to [my/my child’s] medical condition, treatment, and insurance coverage for Biogen to (i) provide [me/my child] with support services (and related information and materials) related to any of Biogen’s products, including but not limited to, online support, financial assistance services, compliance and persistency and other therapy support services, and (ii) conduct data analysis, market research and other necessary internal business activities, and (iii) provide me with information about Biogen’s products, services, and programs for educational or other purposes. I understand that once I sign this Authorization, and [my/my child’s] medical and health information is disclosed to Biogen by the Healthcare Entities, the Health Insurance Portability and Accountability Act (HIPAA) will no longer protect my information because Biogen is not covered by HIPAA. However, Biogen agrees to protect [my/my child’s] health information by using and disclosing it only for purposes authorized in this Authorization or as required by law or regulations. I understand that [my/my child’s] pharmacy provider may receive remuneration from Biogen in exchange for the health information and/or for any therapy support services provided to [me/my child].

I understand that I may refuse to sign this Authorization. I further understand that [my/my child’s] treatment (including with a Biogen product), payment for treatment, insurance enrollment or eligibility for insurance benefits are not conditioned upon my agreement to sign this Authorization; but if I do not sign it or later cancel it, [I/my child] will not be able to receive Biogen’s therapy support services.

I may cancel this Authorization at any time by mailing a letter to: Biogen, ATTN: Patient Services, 5000 Davis Drive, Morrisville, NC, 27560 or emailing privacy@biogen.com. Canceling this Authorization will end consent to further disclosure of [my/my child’s] health information to Biogen by [my/my child’s] Healthcare Entities after they are notified of my cancellation but will not affect previous disclosures by them pursuant to this Authorization. Canceling this authorization will not affect [my/my child’s] ability to receive treatment, payment for treatment, or [my/my child’s] eligibility for health insurance.

This Authorization expires ten (10) years, or such shorter timeframe required by applicable law, from the day I sign it as indicated by the date next to my signature unless otherwise canceled earlier as set forth above.

I have read and understand the Authorization to Share Health Information and agree to the terms.

Please type your name below to provide your signature to authorize the consent:
(If the patient is a minor and you are the patient's Parent/Legal Guardian, please type in your name.)

Enter first name.
Enter last name.
First and last name do not match what was entered in the Patient Information section.

II. Patient Services Authorization

By signing this Authorization, I authorize Biogen, and companies working with Biogen, to provide [me/my child] with support services related to any of Biogen’s products, including but not limited to: online support, financial assistance services, compliance and persistency and other therapy support services, as well as any information or materials related to such services. I understand and agree that personnel, including but not limited to nurses, providing such support services on behalf of Biogen are not employed by [my/my child’s] healthcare professional. I authorize Biogen, and companies working with Biogen, to contact me to provide such services and information by mail, email, fax, telephone call, text message (including calls and text messages made with an automatic telephone dialing system or a prerecorded voice), chat, push notifications and other forms of electronic messaging.

I also authorize Biogen, and companies working with Biogen, to use and disclose [my/my child’s] medical and health information in connection with providing the services, including but not limited to, disclosing [my/my child’s] information to vendors, processors, and service providers for business purposes associated with providing the services, sharing such information with [my/my child’s] healthcare provider, insurance provider, or pharmacy, or disclosing [my/my child’s] information where required by applicable laws or regulations. I also authorize the disclosure of [my/my child’s] health information to specific individuals that I have designated.

I have read and understand the Patient Services Authorization and agree to the terms

Please type your name below to provide your signature to authorize the consent:
(If the patient is a minor and you are the patient's Parent/Legal Guardian, please type in your name.)

Enter first name.
Enter last name.
First and last name do not match what was entered in the Patient Information section.

III. Marketing Authorization

By checking the “Agree to terms” box, I authorize Biogen, and companies working with Biogen, to contact me by mobile or online digital media, mail, email, fax, telephone call, and text message (including autodialed and prerecorded calls and messages) for marketing purposes or otherwise provide me with information about Biogen’s products, services, and programs or other topics of interest, conduct market research or otherwise ask me about [my/my child’s] experience with or thoughts about such topics. I understand and agree that any information that I provide may be used by Biogen for marketing, including targeted online marketing, as well as to develop new products, services, and programs. I understand that Biogen will not sell or transfer [my/my child’s] personal data to any unrelated third party for marketing purposes without my express permission. I understand that my consent is not required as a condition of purchasing or receiving any goods or services from Biogen. I understand that I may revoke this authorization and choose not to receive information from Biogen by sending an email with the subject “Unsubscribe” to privacy@biogen.com, or mailing a letter to Biogen, 5000 Davis Drive, Morrisville, NC 27560. For more information visit biogen.com/privacy.

Make selection.
  • Home Phone : 
  • Mobile Phone : 
  • Email : 

Residents of certain US States (including but not limited to California) may have additional rights regarding the collection, use, maintenance, disclosure, and deletion of your personal information. To understand or exercise those rights California residents please visit https://www.biogen.com/privacy-center.html.

I understand that I have the right to receive a copy of the terms and conditions of my agreement with Biogen, and that I may request that copy at the time of signing or at a later date by contacting Biogen at: Biogen, ATTN: Patient Services, 5000 Davis Drive, Morrisville, NC, 27560 or emailing privacy@biogen.com.



Please choose an option to receive your one-time verification code that you need to enter later to complete the enrollment.

Make selection.

TERMS AND CONDITIONS — PLEGRIDY® (peginterferon beta-1a):

By using the PLEGRIDY Copay Program, the patient acknowledges and confirms that, at the time of usage, they are currently eligible and meet the criteria set forth in the terms and conditions described below.

The PLEGRIDY Copay Program is valid ONLY for patients with commercial insurance who have a valid prescription in accordance with FDA-approved Prescribing Information. The patient must have a US prescriber and a US shipping address. The patient must be a US resident or US citizen. If the patient has federally-funded insurance, such as Medicare, Medicaid, VA, TRICARE®*, or DoD insurance coverage, the patient is not eligible for assistance through the Biogen Copay Program for PLEGRIDY. If the patient obtains a federally-funded plan, such as Medicare, Medicaid, VA, TRICARE, or DoD, at any time during the enrollment period, the patient must notify Biogen immediately, and Biogen may be required to stop copay payments and immediately remove patient from the program.

The PLEGRIDY Copay Program covers only the cost of the drug and does not cover copays related to administration, office visits, or any network penalties levied by patient’s insurance. The assistance provided through the Copay Program will be subject to an annual cap. Once the maximum amount of assistance has been provided, the patient will be responsible for paying 100% of total copay amounts for the remainder of the year after funds are exhausted.

The PLEGRIDY Copay Program is not valid if the costs are eligible to be reimbursed in their entirety by private insurance or other programs.

The PLEGRIDY Copay Program cap will reset every January 1st. These programs are not health insurance or benefit plans. The programs do not obligate the use of a specific product or provider.

The Copay Program is intended to help patients afford PLEGRIDY. Patients may have insurance plans that attempt to increase the amount of patient’s out-of-pocket costs to reflect the availability of support offered by a manufacturer assistance program. In those situations, the program may change its terms including but not limited to removing these patients from the program.

Biogen will not provide copay assistance directly to the patient. All program claims will be paid directly to the patient’s pharmacy upon receipt of appropriate claim submission. The patient’s pharmacy will be responsible for submitting claims directly to the PLEGRIDY Copay Program.

All patients are responsible for appropriately reporting enrollment into the PLEGRIDY Copay Program as required by their insurer. It is the patient’s responsibility to ensure compliance with all terms of their insurance as outlined by their insurance plan.

Eighteen (18) months of inactivity may result in removal from the PLEGRIDY Copay Program.

Biogen reserves the right to modify or discontinue this program with respect to any patient, or in its entirety, at any time. Patient participation does not mean that the patient is entitled to receive assistance indefinitely.

Pharmacist instructions for a patient with an Eligible Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to SS&C Health as a Secondary Payer COB [coordination of benefits] as a copay only billing using BIN 019158 with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). The patient's drug assistance provided through the Copay Program will be subject to an annual cap and reimbursement will be received from SS&C Health. Valid Other Coverage Code required. For any questions regarding SS&C Health online processing, please call the Help Desk at 1-844-373-0987.

*TRICARE is a registered trademark of the Department of Defense; Defense Health Agency. All rights reserved.

What is PLEGRIDY® (peginterferon beta-1a)?:

PLEGRIDY is a prescription medicine used to treat relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease in adults.

It is not known if PLEGRIDY is safe and effective in people under 18 or over 65 years of age.

Important Safety Information

Who should not take PLEGRIDY?

  • Do not take PLEGRIDY if you are allergic to interferon beta or peginterferon, or any of the other ingredients in PLEGRIDY

What is the most important information I should know about PLEGRIDY?

PLEGRIDY can cause serious side effects, including:

  • Liver problems, or worsening of liver problems, including liver failure and death. Symptoms may include yellowing of your skin or the white part of your eye, nausea, loss of appetite, tiredness, bleeding more easily than normal, confusion, sleepiness, dark colored urine, and pale stools. During your treatment with PLEGRIDY you will need to see your healthcare provider regularly. You will have regular blood tests to check for these possible side effect
  • Depression or suicidal thoughts. Symptoms may include new or worsening depression (feeling hopeless or bad about yourself), thoughts of hurting yourself or suicide, irritability (getting upset easily), nervousness, or new or worsening anxiety

Call your healthcare provider right away if you have any of the symptoms listed above.

Before taking PLEGRIDY, tell your healthcare provider about all of your medical conditions, including if you:

  • Are being treated for a mental illness or had treatment in the past for any mental illness, including depression and suicidal behavior
  • Have or had liver problems, low blood cell counts, bleeding problems, heart problems, seizures (epilepsy), thyroid problems, or any kind of autoimmune disease (where the body’s immune system attacks the body’s own cells)
  • Have or had an allergic reaction to rubber or latex. The tip of the cap of the PLEGRIDY prefilled syringe for intramuscular use is made of natural rubber latex
  • Are pregnant or plan to become pregnant. It is not known if PLEGRIDY can harm your unborn baby
  • Are breastfeeding or plan to breastfeed. PLEGRIDY may pass into your breastmilk. Talk to your healthcare provider about the best way to feed your baby if you take PLEGRIDY

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

What are the possible side effects of PLEGRIDY?

PLEGRIDY may cause serious side effects, including:

  • serious allergic reactions. Serious allergic reactions can happen if you take PLEGRIDY. Symptoms may include itching, swelling of the face, eyes, lips, tongue, or throat, trouble breathing, feeling faint, anxiousness, skin rash, hives, or skin bumps. Get emergency help right away if you have any of these symptoms. Talk to your healthcare provider before taking another dose of PLEGRIDY
  • injection site reactions. PLEGRIDY may commonly cause redness, pain, itching or swelling at the place where the injection was given. Call your healthcare provider right away if an injection site becomes swollen and painful or the area looks infected. You may have a skin infection or an area of severe skin damage (necrosis) requiring treatment by a healthcare provider
  • heart problems, including congestive heart failure. Call your healthcare provider right away if you have worsening symptoms of heart failure such as shortness of breath or swelling of your lower legs or feet while using PLEGRIDY
    • Some people using PLEGRIDY may have other heart problems, including low blood pressure, fast or abnormal heartbeat, chest pain, heart attack, or a heart muscle problem (cardiomyopathy)
  • blood problems and changes in your blood tests. PLEGRIDY can decrease your white blood cells or platelets, which can cause an increased risk of infection, bleeding, or anemia and can cause changes in your liver function tests. Your healthcare provider will do tests to monitor for side effects while you use PLEGRIDY
  • thrombotic microangiopathy (TMA). TMA is a condition that involves injury to the smallest blood vessels in your body. TMA can also cause injury to your red blood cells (the cells that carry oxygen to your organs and tissues) and your platelets (cells that help your blood clot) and can sometimes lead to death. Your healthcare provider may tell you to stop taking PLEGRIDY if you develop TMA
  • pulmonary arterial hypertension. Pulmonary arterial hypertension can occur with interferon beta products, including PLEGRIDY. Symptoms may include new or increasing fatigue or shortness of breath. Contact your healthcare provider right away if you develop these symptoms
  • autoimmune diseases. Problems with easy bleeding or bruising (idiopathic thrombocytopenia), thyroid gland problems (hyperthyroidism and hypothyroidism), and autoimmune hepatitis have happened in some people who use interferon beta
  • seizures. Some people have had seizures while taking PLEGRIDY, including people who have never had seizures before

The most common side effects of PLEGRIDY include:

  • flu-like symptoms. Many people who take PLEGRIDY have flu-like symptoms especially early in the course of therapy. These symptoms are not really the flu. You cannot pass it on to anyone else
    • You may be able to manage these flu-like symptoms by taking over-the-counter pain and fever reducers and drinking plenty of water

Flu-like symptoms or other common side effects of PLEGRIDY may include: headache, muscle and joint aches, fever, chills, or tiredness.

These are not all of the possible side effects of PLEGRIDY.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Please see full Prescribing Information and Medication Guide.

This information does not take the place of talking with your healthcare provider about your medical condition or your treatment.

©2026 Biogen. All rights reserved. 04/25 FPS-US-0272 v6

This site is intended for residents 18 years or older of the United States, Puerto Rico, and US territories.

All trademarks are the property of their respective owners.

Biogen Logo

©2026 Biogen. All rights reserved. 04/25 FPS-US-0273 v6

This site is intended for residents 18 years or older of the United States, Puerto Rico, and US territories.

All trademarks are the property of their respective owners.

{"crx-wl-channel":"web","surveyDescription":"Survey1","surveyName":"Survey1","resolveEnrollmentSearchFields":{"patient.firstName":{},"patient.lastName":{},"patient.gender":{},"patient.dob":{},"patient.postalCode":{}},"verifyOtp":true,"maxResendLimit":"3","otpCommunicationType":"both","otpEnrollmentStatus":"rejected","otpValidTime":"15","otpValidUnit":"minutes","emailCommunication":{"emailTemplateId":"Biogen_OTPTemplate","emailAssetId":"8aba3099-9b3b-e911-80c8-005056a96666.html","emailFrom":"no-reply@connectiverx.com","emailTo":"","emailSubject":"Biogen Copay Program Temporary Verification Code","emailFormFields":[{"Id":"OTP","Font":null,"FontSize":null,"Text":"000000"}]},"smsCommunication":{"application":"000000"}}