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Complete this form when you are seeking reimbursement after paying the provider for your treatment. The instructions for using the program with these providers are included on the form.
OCREVUS is a prescription medicine used to treat adults with relapsing or primary progressive forms of multiple sclerosis. It is not known if OCREVUS is safe or effective in children.
Do not receive OCREVUS if you have an active hepatitis B virus (HBV) infection.
Do not receive OCREVUS if you have had a life threatening allergic reaction to OCREVUS. Tell your healthcare provider if you have had an allergic reaction to OCREVUS or any of its ingredients in the past.
OCREVUS can cause serious side effects, including:
OCREVUS may cause serious side effects, including:
Most common side effects include infusion reactions and infections.
These are not all the possible side effects of OCREVUS.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
For more information, go to www.OCREVUS.com or call 1-844-627-3887.
The OCREVUS Prepaid Mastercard® is issued by Comerica Bank pursuant to license by Mastercard International. No cash or ATM access. The card can be used only to purchase prescriptions at participating merchant locations where Debit Mastercard is accepted.