⭐️ The newest Ministry’s response and my response back ⭐️  - it’s a long one!

**I’m sharing the entire exchange below so there is no paraphrasing, no cherry-picking, and no misunderstanding of what patients are being told when it comes to MS treatment access in British Columbia.**

This conversation centers on anti-CD20 therapies for relapsing-remitting multiple sclerosis and whether medications are being treated as interchangeable based on cost and class, rather than science, safety, clinical outcomes, and lived experience.
This time - I believe they intentionally responded without keeping my previous correspondence attached.. which was something they could not argue and still resorted to the same response from every other email - addressing absolutely nothing that I have requested.. 

While the Ministry highlights alternative medications like Mavenclad and Tysabri, these are entirely different drug classes and do not address the issue being raised:
restricted access within the anti-CD20 class, even when patients are clinically stable, experiencing safety complications, or advised by their neurologists to switch therapies.

This is not theoretical.
These policies affect infection risk, immune function, relapse rates, disability progression, and long-term health outcomes.

Patients are not averages.
We are not interchangeable.
And our treatment decisions cannot be reduced to cost alone.

I’m sharing this because transparency matters and because people living with MS deserve policies that reflect science, real-world evidence, and lived experience, not blanket assumptions.

Please read both responses in full.

📄 RESPONSE FROM THE MINISTRY OF HEALTH

(Shared unedited with only removing the name of the responder )

Dear Cassandra Nieman:

Thank you for your emails of December 17, 2025, and January 14, 2026, regarding PharmaCare coverage for ocrelizumab (Ocrevus) and ofatumumab (Kesimpta) for the treatment of relapsing-remitting multiple sclerosis (RRMS).

As discussed previously, although ocrelizumab and ofatumumab are not eligible PharmaCare benefits for the treatment of RRMS, the mechanism of action for both ocrelizumab and ofatumumab is highly similar to that of rituximab, which is a PharmaCare benefit.

The annual cost of rituximab for the treatment of RRMS is approximately $6,000 per patient, whereas the annual cost for ocrelizumab or ofatumumab for the treatment of RRMS is approximately $30,000 per patient, which is a significant difference.

PharmaCare’s coverage decisions may be revised or reconsidered in consideration of new evidence. The Ministry may modify a PharmaCare coverage decision for many reasons, including economic reasons (such as the introduction of less-expensive generic versions of brand-name drugs, manufacturer price increases or decreases, or changes in the marketplace resulting from the introduction of innovative therapies) and therapeutic reasons (such as the introduction of new clinical effectiveness or safety data). PharmaCare continually reviews the formulary, as new clinical and safety evidence is continually published, and the prices of drugs constantly change.

PharmaCare is currently reviewing two potential first-line treatments for RRMS, cladribine (Mavenclad®) and natalizumab (Tysabri™).

At present, PharmaCare is not considering listing ocrelizumab or ofatumumab as PharmaCare benefits for RRMS.

I realize this is not the response you were seeking; however, I trust it serves to clarify the Ministry’s position.

Thank you for the opportunity to respond.

Sincerely,
—————-
Executive Director, Therapeutic Assessment and Access
Health System Policy and Oversight Division, Ministry of Health

✉️ MY RESPONSE BACK TO THE MINISTRY

Dear ——————-, 

Thank you for your response and for outlining the Ministry’s current position regarding PharmaCare coverage for relapsing-remitting multiple sclerosis (RRMS). I appreciate the clarification provided and acknowledge the Ministry’s ongoing review of potential treatment options for people living with MS in British Columbia - it would of been nice to keep the original correspondence attached to reflect the full discussion. 

That said, I must respectfully note that the response does not meaningfully engage with the core issues raised in my previous correspondence…specifically, the clinical, safety, and continuity-of-care rationale for access to Health Canada–approved anti-CD20 therapies, including ocrelizumab (Ocrevus) and ofatumumab (Kesimpta).

Anti-CD20 Therapies Are Not Clinically Interchangeable With Other First-Line Options

While I welcome the Ministry’s consideration of Cladribine-Mavenclad and Natalizumab-Tysabri, these therapies represent entirely different mechanisms of action, class, safety profiles, and treatment paradigms. They are not substitutes for anti-CD20 therapies, nor do they address the circumstances of patients who:
•Have already been clinically stabilized on an anti-CD20 therapy outside of Rituxan
•Have contraindications or elevated risk profiles for alternative mechanisms
•Require durable, continuous B-cell–directed therapy based on disease course

Introducing non–anti-CD20 therapies as “potential first-line treatments” does not resolve the underlying issue of restricted access within the anti-CD20 class, particularly when patients are being required to remain on rituximab despite safety complications or specialist recommendations to transition to another approved therapy in the same CLASS.

Mechanism of Action Does Not Equal Clinical Interchangeability

While it is accurate that rituximab, ocrelizumab, and ofatumumab all target CD20-positive B cells, shared mechanism of action does not imply clinical equivalence. Differences in molecular structure, dosing schedules, pharmacodynamics, immunogenicity, regulatory approval, stability and real-world safety outcomes are well recognized by MS specialists and reflected in contemporary clinical decision-making. Not all Anti-CD20 target or sustain the same outcome in every patient .  

As outlined in my prior submission, real-world evidence demonstrates meaningful differences in safety and immune-related outcomes between rituximab and ocrelizumab, including higher rates of infection-related hospitalizations and hypogammaglobulinemia requiring IVIg supplementation in patients receiving rituximab. Along with B.C.’s own newest research showing a potential of a 50% relapse increase on Rituxan compared to Ocrevus. These differences are directly relevant to patient safety and long-term health system burden and cannot be reduced to mechanism-of-action arguments alone.

Cost Alone Cannot Justify Forced Therapy or Loss of Continuity of Care

The Ministry’s emphasis on annual drug acquisition costs, while understandable from a budgetary perspective, does not address the total cost of care, including:
•Hospitalizations and infection-related complications
•Long-term immune deficiency and IVIg dependence
•Loss of disease control or cumulative neurological injury following forced switches

Nor does it address the ethical and clinical implications of penalizing patients who initiated ocrelizumab or ofatumumab under private insurance based on specialist recommendation, only to be forced into a different therapy when that insurance ends. Continuity of effective care is a foundational principle of chronic disease management, particularly in a condition where irreversible neurological harm can occur and where even switching medications within the same class can have a catastrophic effect on stability. 

Evidence Uncertainty Should Support Access, Not Restriction

As acknowledged by ICER ( which you had cited to another patient personally ) and other health technology assessment bodies, comparative evidence between anti-CD20 therapies relies heavily on observational data and carries inherent uncertainty. However, uncertainty cannot be selectively invoked to justify exclusion while disregarding consistent safety signals and clinician judgment.

Where uncertainty exists…particularly in the context of irreversible disease - it should support broader access and individualized decision-making, not restrictive policies that assume interchangeability and limit clinician discretion.

I respectfully submit that the Ministry’s current position does not adequately reflect:
•The clinical complexity of RRMS
•The non-interchangeability of disease-modifying therapies
•The real-world safety consequences already being experienced by patients
•Or the importance of continuity of care for those stable on anti-CD20 therapy

I welcome continued dialogue and would appreciate clarification on how the Ministry intends to address patients who are clinically stable on anti-CD20 therapies, experiencing safety issues on rituximab, or advised by their neurologists that another anti-CD20 therapy is more appropriate, particularly when such therapies are publicly funded in every other Canadian province.

Thank you again for your time and consideration. I look forward to your response.

Sincerely,
Cassandra Nieman
Richmond, British Columbia
Ocrevus Patient & MS Advocate

I will create a new update with my original correspondence prior to this response. 

🧡Please continue to share the petition, We need visibility! 🧡