Forms and Documents

To download multiple files at once, select the checkbox next to each file you would like to download from the list below then click Download Selected. Documents will be downloaded as a .zip file.

OCREVUS Access Solutions Enrollment Forms

The OCREVUS Start Form is required for enrollment in OCREVUS Access Solutions.

Other Important Documents

Sample Letter of Medical Necessity – Patient Converting to OCREVUS

Use this sample letter as a guide when you draft a letter of medical necessity and submit a request for prior authorization to the patient's health insurance plan. This version is specifically written for patients switching to OCREVUS from a different therapy. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for OCREVUS

Sample Letter of Medical Necessity – Patient New to OCREVUS

Use this sample letter as a guide when you draft a letter of medical necessity and submit a request for prior authorization to the patient's health insurance plan. This version is specifically written for patients starting treatment with OCREVUS. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information 

Sample coding for OCREVUS

Sample Letter of Medical Necessity – Patient to Remain on OCREVUS

Use this sample letter as a guide when you draft a letter of medical necessity and submit a request for prior authorization or reauthorization to the patient's health insurance plan. This version is specifically written for patients remaining on OCREVUS. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for OCREVUS

Sample Appeal Letter – Patient Converting to OCREVUS

Use this sample letter as a guide as you draft an appeal letter in the event the patient's health insurance plan denies coverage for OCREVUS. This version is specifically written for patients switching to OCREVUS from a different therapy. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for OCREVUS

Sample Appeal Letter – Patient New to OCREVUS

Use this sample letter as a guide as you draft an appeal letter in the event the patient's health insurance plan denies coverage for OCREVUS. This version is specifically written for patients new to OCREVUS. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for OCREVUS

Sample Appeal Letter – Patient to Remain on OCREVUS

Use this sample letter as a guide as you draft an appeal letter in the event the patient's health insurance plan denies coverage for OCREVUS. This version is specifically written for patients remaining on OCREVUS. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for OCREVUS

 

Enrolling in the Genentech Patient Foundation

The Genentech Patient Foundation gives free medicine to people who don't have insurance coverage or who have financial concerns and to people who meet certain income criteria.

Fax Cover Letter

Use this cover sheet when faxing documents to OCREVUS Access Solutions.

PAN=Patient Authorization and Notice of Request for Transmission of Health Information to Genentech Access Solutions and Genentech® Access to Care Foundation.

SMN=Statement of Medical Necessity.

Important Safety Information & Indication

Indications

OCREVUS is indicated for the treatment of adult patients with relapsing or primary progressive forms of multiple sclerosis.

Contraindications

OCREVUS is contraindicated in patients with active hepatitis B virus infection and in patients with a history of life-threatening infusion reaction to OCREVUS.

Warnings and Precautions

Infusion Reactions:

Management recommendations for infusion reactions depend on the type and severity of the reaction. Permanently discontinue OCREVUS if a life-threatening or disabling infusion reaction occurs.

Infections:

Delay OCREVUS administration in patients with an active infection until the infection is resolved. Vaccination with live-attenuated or live vaccines is not recommended during treatment with OCREVUS and after discontinuation, until B-cell repletion.

Malignancies:

An increased risk of malignancy, including breast cancer, may exist with OCREVUS.

Most Common Adverse Reactions

RMS: The most common adverse reactions in RMS trials (incidence ≥10% and >REBIF): upper respiratory tract infections and infusion reactions.

PPMS: The most common adverse reactions (≥10% and >placebo): upper respiratory tract infections, infusion reactions, skin infections, and lower respiratory tract infections.

For additional safety information, please see the full Prescribing Information and Medication Guide.