Ocrevus — Medical Mutual

Initial criteria

• Patient age ≥ 18 years AND
• Prescribed by or in consultation with a physician who specializes in MS or a neurologist AND
• Used as a single-agent therapy (not in combination with other MS disease-modifying agents; not used with Avonex, Betaseron, Extavia, Rebif, Plegridy, Copaxone, Glatopa, Gilenya, Aubagio, Tecfidera, Tysabri, Lemtrada) AND
• Patient has been screened for Hepatitis B virus and does not have active infection AND
• Site of care medical necessity is met

Reauthorization criteria

• Patient continues Ocrevus therapy AND
• Beneficial response to therapy documented AND
• Site of care medical necessity is met

Approval duration

1 year