Ocrevus Zunovo — Medical Mutual

Initial criteria

• Age ≥ 18 years
• Diagnosis of a relapsing form of multiple sclerosis (RRMS, SPMS with relapses, or PRMS)
• Meets one of the following: (a) Highly active/aggressive MS defined as ≥ 2 relapses in the past year and ≥ 1 gadolinium-enhancing lesion OR EDSS score ≥ 6 within 5 years of symptom onset OR ≥ 2 MRI with new or enlarging T lesions or Gd+ lesions during past 12 months while on disease modifying treatments; OR (b) Previously tried at least one generic MS therapy (examples: interferon beta-1a, interferon beta-1b, peginterferon beta-1a, glatiramer acetate)
• Prescribed by, or in consultation with, a physician who specializes in the treatment of MS and/or a neurologist
• Used as single agent therapy (not in combination with any disease-modifying therapy for MS such as Avonex, Betaseron, Briumvi, Extavia, Rebif, Plegridy, Copaxone, Glatopa, Gilenya, Aubagio, Tecfidera, Tysabri, Lemtrada)
• Screened for hepatitis B virus prior to initiation and does not have active disease
• Site of care medical necessity criteria is met

Reauthorization criteria

• Beneficial response to therapy
• Site of care medical necessity is met

Approval duration

1 year