By Counterforce Health Team in Ocrevus (ocrelizumab) —

Blue Cross Blue Shield Ohio Coverage Criteria for Ocrevus: What Counts as "Medically Necessary"?

Answer Box: Getting Ocrevus Covered by Blue Cross Blue Shield in Ohio

Blue Cross Blue Shield Ohio requires prior authorization for Ocrevus (ocrelizumab) with specific medical necessity criteria. To qualify: you must be 18+, have confirmed MS diagnosis via MRI, complete hepatitis B screening, and get approval through the NovoLogix portal. Fastest path: Have your neurologist submit complete documentation including prior therapy history and clinical notes. Start today: Call Blue Cross Blue Shield member services at the number on your card to confirm your plan's specific requirements and get the prior authorization process started.

Table of Contents

  1. Policy Overview: How Blue Cross Blue Shield Ohio Covers Ocrevus
  2. Indication Requirements: What MS Diagnoses Qualify
  3. Step Therapy & Exceptions: Required Trials and Medical Overrides
  4. Quantity & Frequency Limits: Dosing and Renewal Rules
  5. Required Diagnostics: Labs, Imaging, and Documentation
  6. Site of Care & Specialty Pharmacy Requirements
  7. Evidence to Support Medical Necessity
  8. Sample "Meets Criteria" Narrative
  9. Edge Cases: Special Situations and Escalation
  10. Appeals Playbook for Ohio
  11. Common Denial Reasons & How to Fix Them
  12. FAQ: Your Most Common Questions

Policy Overview: How Blue Cross Blue Shield Ohio Covers Ocrevus

Blue Cross Blue Shield Ohio operates as part of the larger BCBS Association network, with 33 independent Blue plans nationwide that share common coverage frameworks while maintaining state-specific policies. In Ohio, the primary Blue Cross Blue Shield plan is operated by Anthem, which holds approximately 31% of the state's health insurance market share.

Plan Types and Coverage Structure

Commercial Plans (HMO/PPO): Most Blue Cross Blue Shield Ohio commercial members are subject to prior authorization requirements for Ocrevus as of October 2024. The requirements apply to groups participating in the standard Medical Drug Prior Authorization Program, though some employer groups may opt out.

Federal Employee Program (FEP): FEP members typically have separate criteria and may be exempt from certain commercial requirements.

Medicare and Medicaid: These follow federal and Ohio state-specific guidelines, which may differ from commercial policies.

Where to Find Official Documentation

The most current policies are available through:

Note: Requirements only apply to groups participating in Blue Cross Blue Shield's prior authorization program. Check the "Specialty Pharmacy Prior Authorization Master Opt-in/out Group List" to confirm your plan's participation.

Indication Requirements: What MS Diagnoses Qualify

FDA-Approved Indications

Ocrevus is FDA-approved for two primary multiple sclerosis categories:

Relapsing Forms of MS including:

  • Clinically Isolated Syndrome (CIS)
  • Relapsing-Remitting MS (RRMS)
  • Active Secondary Progressive MS (SPMS)

Primary Progressive MS (PPMS) in adults

Blue Cross Blue Shield Specific Criteria

Age Requirements: Patients must be 18 years or older for all indications. For primary progressive MS, additional restrictions may apply, with some policies requiring patients to be under 65 years of age.

Functional Status for PPMS: Patients with primary progressive MS must demonstrate they can ambulate more than 5 meters and are not considered wheelchair-bound. Some policies specify an Expanded Disability Status Scale (EDSS) score of ≤ 6.5.

Relapsing MS Activity Requirements: For relapsing forms, documentation must show:

  • Ability to ambulate without aid or rest for at least 100 meters
  • At least two relapses in the previous two years, OR
  • One relapse in the previous year

Step Therapy & Exceptions: Required Trials and Medical Overrides

Standard Step Therapy Requirements

Blue Cross Blue Shield Ohio typically requires patients to have tried and failed, or have contraindications to, at least one other disease-modifying therapy before approving Ocrevus. Common first-line therapies include:

  • Interferons (Avonex, Betaseron, Copaxone)
  • Glatiramer acetate
  • Oral agents (Tecfidera, Aubagio, Gilenya)

Medical Exception Pathways

Severe Disease: For patients with highly active or severe MS, monoclonal antibody therapy like Ocrevus may be considered reasonable first-line treatment without step therapy requirements.

Contraindications: Document specific medical reasons why other therapies cannot be used:

  • Liver function abnormalities preventing oral DMT use
  • Injection site reactions or needle phobia
  • Cardiac conditions preventing certain therapies
  • Prior serious adverse reactions

Intolerance Documentation: Provide detailed records of:

  • Specific adverse events experienced
  • Duration of therapy attempted
  • Clinical notes documenting discontinuation reasons

Quantity & Frequency Limits: Dosing and Renewal Rules

Approved Dosing Regimens

Initial Treatment: 300 mg IV infusions given 2 weeks apart Maintenance: 600 mg IV infusion every 6 months

Maximum Coverage: Up to 920 billable units every 6 months

Renewal Requirements

Authorization Duration: Initial approvals typically last 12 months and may be renewed annually thereafter.

Renewal Documentation: Must demonstrate:

  • Continued medical necessity
  • Absence of significant adverse events
  • Clinical stability or improvement
  • Ongoing appropriate monitoring

Required Diagnostics: Labs, Imaging, and Documentation

Mandatory Screening Tests

Hepatitis B Virus (HBV) Screening: Required before treatment initiation

  • Negative HBsAg (Hepatitis B surface antigen)
  • Negative anti-HBV tests
  • If at risk for HBV infection, treatment must be initiated before Ocrevus

Baseline Immunoglobulin Assessment: Document baseline serum immunoglobulin levels with prescriber agreement to monitor throughout therapy.

Imaging Requirements

MRI Confirmation: Multiple sclerosis diagnosis must be confirmed by MRI and documented in laboratory reports.

Timing Requirements: Diagnostic imaging should be recent and support the current MS phenotype being treated.

Clinical Documentation Checklist

✓ Complete medical history and physical exam notes
✓ Neurological examination findings
✓ Prior therapy history with specific outcomes
✓ Current functional status assessment
✓ Contraindications to alternative therapies
✓ Treatment goals and expected outcomes

Site of Care & Specialty Pharmacy Requirements

Approved Administration Sites

Automatic Approval for administration in:

  • Doctor's or healthcare provider's office
  • Ambulatory infusion center
  • Patient's home via home infusion therapy provider

Additional Documentation Required for:

  • Outpatient hospital settings (must justify why other sites are inappropriate)

Specialty Pharmacy Routing

Ocrevus is typically routed through specialty pharmacy networks. Patients should:

  • Confirm their plan's preferred specialty pharmacy
  • Understand any network restrictions
  • Verify coverage for out-of-network providers if needed

Evidence to Support Medical Necessity

Primary Evidence Sources

FDA Labeling: Reference the official FDA-approved prescribing information for Ocrevus, which provides the strongest regulatory support for medical necessity.

Clinical Guidelines:

  • National Comprehensive Cancer Network (NCCN) Guidelines
  • American Academy of Neurology practice parameters
  • National Multiple Sclerosis Society recommendations

Peer-Reviewed Literature: Key studies demonstrating efficacy:

  • OPERA I and OPERA II trials for relapsing MS
  • ORATORIO trial for primary progressive MS

How to Cite Evidence Effectively

When submitting appeals or prior authorization requests:

  • Be specific: Reference exact study names, publication years, and key findings
  • Match indication: Ensure cited evidence aligns with the patient's specific MS phenotype
  • Include outcomes data: Highlight reduction in relapse rates, disability progression, or MRI activity

Sample "Meets Criteria" Narrative

Medical Necessity Justification Template:

"[Patient name] is a [age]-year-old patient with [specific MS type] confirmed by MRI on [date]. The patient meets Blue Cross Blue Shield criteria for Ocrevus coverage as they have: (1) confirmed MS diagnosis documented by laboratory report/MRI, (2) completed required hepatitis B screening with negative results, (3) baseline immunoglobulin assessment completed, (4) no active infections present, and (5) [prior therapy history/contraindications]. Ocrevus is FDA-approved for this indication and is being prescribed by a neurologist consistent with standard clinical practice. The requested dosing (initial 300mg x2, then 600mg every 6 months) aligns with FDA labeling and clinical guidelines."

Key Phrases for Medical Necessity

  • "FDA-approved indication"
  • "Standard of care per clinical guidelines"
  • "Medically appropriate and necessary"
  • "Consistent with evidence-based treatment"
  • "No suitable alternatives available"

Edge Cases: Special Situations and Escalation

Pregnancy and Family Planning

Contraception Requirements: Document counseling about effective contraception during treatment and for 6 months after last dose.

Pregnancy Planning: If pregnancy is planned, document discussion of treatment interruption and alternative options.

Comorbidities

Active Infections: Absolute contraindication; must resolve before treatment Immunocompromised States: Require additional evaluation and monitoring Prior Malignancy: May require oncology clearance

Escalation Pathways

Peer-to-Peer Review: Request clinical discussion between prescribing physician and plan medical director Expedited Appeals: For urgent clinical situations where delays could worsen outcomes External Review: Through Ohio Department of Insurance if internal appeals fail

Appeals Playbook for Ohio

Internal Appeal Process

First-Level Appeal:

  • Timeline: Must be filed within 180 days of denial
  • Response time: 15 days for non-urgent, 72 hours for urgent
  • Submit to: Blue Cross Blue Shield appeals department (address on denial letter)

Second-Level Appeal:

  • Available if first appeal is denied
  • Timeline: 60 days from first-level denial
  • Independent medical review required

External Review Through Ohio Department of Insurance

Eligibility: Available after exhausting internal appeals Timeline: 180 days from final internal denial to request external review Contact: Ohio Department of Insurance Consumer Services at 1-800-686-1526 Process: Independent Review Organization (IRO) conducts medical review

From our advocates: "We've seen the strongest appeal outcomes when families include a detailed timeline of the patient's MS progression, specific functional impacts, and clear documentation of why Ocrevus is uniquely appropriate for their situation. One composite case involved a young professional whose relapsing MS wasn't controlled on first-line therapies—the appeal succeeded by emphasizing both clinical necessity and the patient's need for a therapy compatible with their work schedule."

Required Appeal Documents

✓ Original denial letter
✓ Complete medical records
✓ Prescriber letter of medical necessity
✓ Clinical notes from recent visits
✓ MRI reports and lab results
✓ Documentation of prior therapy failures
✓ Relevant clinical guidelines or studies

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No confirmed MS diagnosis Submit MRI reports and neurologist evaluation Recent MRI with radiologist interpretation, neurologist consultation notes
Missing hepatitis B screening Complete required lab work HBsAg and anti-HBV test results
No trial of other DMTs Document contraindications or provide trial history Prior therapy records, adverse event documentation
Combination therapy concern Confirm single-agent use Current medication list, prescriber attestation
Site of care not approved Justify hospital-based infusion Medical necessity for hospital setting, comorbidity documentation

FAQ: Your Most Common Questions

How long does Blue Cross Blue Shield prior authorization take in Ohio? Standard prior authorization decisions are typically made within 15 business days. Expedited reviews for urgent situations are completed within 72 hours.

What if Ocrevus is not on my plan's formulary? You can request a formulary exception by demonstrating medical necessity and lack of suitable alternatives. This requires detailed clinical documentation.

Can I request an expedited appeal? Yes, if delaying treatment would seriously jeopardize your health or ability to regain maximum function. Your physician must provide supporting documentation.

Does step therapy apply if I tried other therapies outside Ohio? Yes, prior therapy history from other states typically counts toward step therapy requirements. Ensure you have complete medical records transferred.

What happens if my appeal is denied? You can request external review through the Ohio Department of Insurance within 180 days. This provides independent medical review by experts not affiliated with your insurance company.

How much does Ocrevus cost without insurance? Ocrevus is a high-cost specialty biologic. List prices vary, but annual costs can exceed $65,000. Patient assistance programs may be available through Genentech Access Solutions.

Getting help with your Blue Cross Blue Shield Ohio appeal: If you're struggling to navigate the prior authorization or appeals process for Ocrevus, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform ingests denial letters and clinical notes to draft point-by-point rebuttals aligned to your plan's specific rules, pulling the right medical evidence and operational details payers expect. This can significantly streamline the approval process and reduce back-and-forth with your insurance company.

For additional support, contact:

  • Ohio Department of Insurance Consumer Services: 1-800-686-1526
  • Blue Cross Blue Shield Member Services: Number on your insurance card
  • National MS Society: 1-800-344-4867

Sources & Further Reading

This article provides educational information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals, consider consulting with qualified patient advocates or legal professionals familiar with Ohio insurance law.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.