OCRELIZUMAB

OCRELIZUMAB (11237K)

ocrelizumab 300 mg/10 mL injection, 10 mL vial
11237K
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9523)

Indication: Multiple sclerosis
Treatment phase: Initial treatment

Restriction (Streamlined authority code: 9635)

Indication: Multiple sclerosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 0 DPMQ: $16,705.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ocrevus

OCRELIZUMAB (11242Q)

ocrelizumab 300 mg/10 mL injection, 10 mL vial
11242Q
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7699)

Indication: Multiple sclerosis
Treatment phase: Initial treatment

Restriction (Streamlined authority code: 7386)

Indication: Multiple sclerosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 0 DPMQ: $16,656.36 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ocrevus

OCRELIZUMAB (15113K)

ocrelizumab 920 mg/23 mL injection, 23 mL vial
15113K
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9523)

Indication: Multiple sclerosis
Treatment phase: Initial treatment

Restriction (Streamlined authority code: 9635)

Indication: Multiple sclerosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $16,705.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ocrevus SC

OCRELIZUMAB (15120T)

ocrelizumab 920 mg/23 mL injection, 23 mL vial
15120T
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7699)

Indication: Multiple sclerosis
Treatment phase: Initial treatment

Restriction (Streamlined authority code: 7386)

Indication: Multiple sclerosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $16,656.36 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ocrevus SC