Coverage is provided in the following conditions:
ï· Patient is 18 years or older (unless otherwise specified); AND
ï· Patient has been screened for the presence of Hepatitis B virus (HBV) prior to initiating treatment AND does not have active disease (i.e., positive HBsAg and anti-HBV tests); AND
ï· Patient has baseline serum immunoglobulins assessed; AND
Universal Criteria
ï· Patient will not receive live vaccines concurrently with ocrelizumab; AND
ï· Patient does not have an active infection; AND
Multiple Sclerosis
ï· Patient must have a confirmed diagnosis* of multiple sclerosis (MS) as documented by laboratory report (i.e., MRI); AND
ï· Must be used as single agent therapy; AND
o Patient has a diagnosis of a relapsing form of MS [i.e., relapsing-remitting MS (RRMS)*, active secondary progressive disease (SPMS)**, or clinically isolated syndrome (CIS)***]; OR
o Patient has a diagnosis**** of primary progressive MS (PPMS); AND
ï§ Patient is less than 65 years; AND
ï§ Patient has an expanded disability status scale (EDSS) score of ≤ 6.5 † FDA Approved Indication(s)
