Ocrevus — Medical Mutual
Relapsing forms of multiple sclerosis (relapsing-remitting MS, secondary-progressive MS with relapses, or progressive-relapsing MS)
Initial criteria
- Patient age ≥ 18 years AND
- Diagnosis of a relapsing form of multiple sclerosis (RRMS, SPMS with relapses, or PRMS) AND
- Patient meets one of the following: i. Patient has highly active/aggressive MS as determined by: (a) ≥ 2 relapses in the past year and ≥ 1 gadolinium-enhancing lesion; OR (b) EDSS score ≥ 6 within 5 years of symptom onset; OR (c) ≥ 2 MRI with new or enlarging T lesions or Gd+ lesions during past 12 months while receiving disease-modifying treatments OR ii. Patient has previously tried at least one generic MS therapy (examples: interferon beta-1a, interferon beta-1b, peginterferon beta-1a, glatiramer acetate) 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, Briumvi, 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