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The patient completes this form when they are seeking reimbursement after paying the provider for their treatment. The instructions for using the program with these providers are included on the form.
This form is used when the practice prefers payment by check.
This form is used to initiate the EFT registration process when the practice chooses not to use check reimbursements. It is a one-time registration completed by the practice.
This form is used when the drug is not clearly identified on the explanation of benefits (EOB). This form can accompany the EOB.
OCREVUS is indicated for the treatment of adult patients with relapsing or primary progressive forms of multiple sclerosis
OCREVUS is contraindicated in patients with active hepatitis B virus infection and/or a in patients with a history of life threatening infusion reaction to OCREVUS.
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
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
An increased risk of malignancy, including breast cancer, may exist with OCREVUS.
RMS: The most common adverse reactions (≥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 track infections
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.