Ocrelizumab (Ocrevus)

OFFICE ADMINISTRATION [medical benefit]

Indications for Prior Authorization:

  • Treatment of adults with relapsing or primary progressive forms of multiple sclerosis (MS)

Patients must meet the following criteria for the indication(s) above:

  • Relapsing, remitting MS (RRMS) or primary progressive MS (PPMS) confirmed by a neurologist; AND
  • Will not be authorized for anyone with active HBV infection; AND
  • This drug may not be used in combination with any other disease modifying therapy for MS either oral or injectable (e.g., Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa, Rebif, Tecfidera, Tysabri or mitoxantrone)
  • For RRMS approved for Monotherapy if:
    • Patients with RRMS who are poor responders (tried/failed an adequate trial as confirmed by chart note documentation) to at least one first-line treatment (oral or injectable), and who develop accumulating disability despite therapy

Dosing:

  • Initial dose is 300mg IV infusion, followed 2 weeks later by a second 300mg IV infusion.  Maintenance is 600mg IV infusion once every 6 months.
  • Premedication with methylprednisolone or an antihistamine is recommended
  • Consider use of an antipyretic

Approval:

  • 1 year

Last review date: June 12, 2017

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