• Ocrevus Motivation Form

  • Welcome to the Ocrevus (ocrelizumab) motivation form.

    This tool will assist you in compiling a comprehensive draft letter when requesting reimbursement for Ocrevus (ocrelizumab) from funders. The request letter will be sent to your email for you to review before your submission to the funder. It is not intended to substitute independent medical judgement and approval is not guaranteed by Essential Medical Guidance (EMGuidance) or Roche.

    This motivation form should be used for patients with relapsing forms of multiple sclerosis (RMS) or for patients with primary progressive multiple sclerosis (PPMS).

    Ocrevus (ocrelizumab) is indicated for:

    • Patients with relapsing forms of multiple sclerosis (RMS) to suppress relapses and disease progression (clinical and subclinical disease activity).
    • The first-line treatment of patients with primary progressive multiple sclerosis (PPMS) to delay disease progression and reduce deterioration in walking speed.
  • Does the patient have any of the below conditions that make them ineligible to receive Ocrevus?*

  • Based on the information you have provided, Ocrevus (ocrelizumab) is contraindicated for your patient. Should you need more information, please contact Roche at illovo.medinfo@roche.com.

  • What phenotype of multiple sclerosis does the patient have*

  • Please note - Questions marked with a red asterisk (*) are mandatory and need to be completed before proceeding.

  • Should be Empty: