By Counterforce Health Team in Ocrevus (ocrelizumab) —

Getting Ocrevus (Ocrelizumab) Covered by Blue Cross Blue Shield in New Jersey: Prior Authorization, Appeals & Cost Assistance

Answer Box: Quick Path to Ocrevus Coverage in New Jersey

Blue Cross Blue Shield in New Jersey requires prior authorization for Ocrevus through their specialty management program. To get started: (1) Have your neurologist submit a PA request through MagellanRx Management or call 1-800-424-4508, (2) ensure you meet clinical criteria for relapsing or primary progressive MS, and (3) document any failed DMT trials. If denied, New Jersey's Independent Health Care Appeals Program (IHCAP) provides external review through Maximus Federal Services. Apply for manufacturer copay assistance (up to $20,000/year) at ocrevuscopay.com if you have commercial insurance.

Table of Contents

Understanding Your Blue Cross Blue Shield Coverage

Ocrevus (ocrelizumab) is a specialty biologic that requires careful navigation of your Blue Cross Blue Shield benefits in New Jersey. The largest BCBS plan in the state, Horizon Blue Cross Blue Shield, covers approximately 39% of the market and has specific protocols for specialty medications.

Coverage Basics

Formulary Status: Ocrevus is typically covered under BCBS medical benefits rather than pharmacy benefits, since it's administered by IV infusion every six months. Horizon BCBS operates an open formulary system, meaning FDA-approved medications are generally included, though specialty drugs require prior authorization.

Site of Care Requirements: As of November 2024, Ocrevus is included in Horizon's Site of Administration Program, which means specific infusion centers may be preferred or required for coverage.

Note: Out-of-network infusion centers can result in significantly higher costs or outright denials. Always verify your provider's network status before scheduling.

Prior Authorization Requirements

Clinical Criteria

Blue Cross Blue Shield requires documentation that you meet FDA-approved indications for Ocrevus:

  • Relapsing MS forms: Including clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), or active secondary progressive MS (SPMS)
  • Primary progressive MS in adults
  • Age requirement: 18 years or older

Required Documentation

Your neurologist must submit:

  1. Diagnosis confirmation with appropriate ICD-10 codes
  2. Prior therapy history (plan-dependent step therapy requirements)
  3. Hepatitis B screening results and vaccination status
  4. Contraindication documentation if other DMTs cannot be used
  5. Treatment goals and monitoring plan

Submission Process

For Horizon BCBS patients: Submit requests through MagellanRx Management or call 1-800-424-4508. Other New Jersey BCBS plans may use different specialty pharmacy benefit managers—check your member portal or call the number on your insurance card.

Timeline: Most PA decisions are made within 72 hours for standard requests, 24 hours for expedited requests when delay could cause serious harm.

Cost Breakdown and Assistance Options

Understanding Your Costs

Ocrevus has a list price of approximately $78,858 per year, but your actual cost depends on your specific BCBS plan design:

  • In-network: Typically 10-30% coinsurance after deductible
  • Out-of-network: 40-50% coinsurance, possible balance billing
  • Deductible: Applies before coinsurance kicks in

Manufacturer Assistance

Ocrevus Co-Pay Program: Eligible patients with commercial insurance can receive up to $20,000 per year toward out-of-pocket costs. This program covers both drug and administration costs but excludes office visit fees.

Eligibility requirements:

  • Commercial (private) insurance as primary payer
  • Not eligible for Medicare, Medicaid, TRICARE, or VA benefits
  • Prescription for FDA-approved indication

To apply: Visit ocrevuscopay.com or call 1-844-627-3887.

New Jersey State Programs

Pharmaceutical Assistance to the Aged and Disabled (PAAD):

  • Income limits (2025): Less than $53,446 (single) or $60,690 (married)
  • Coverage: $5 copay for generics, $7 for brand-name drugs
  • Apply: Through NJSave online portal or call 1-800-792-9745

Senior Gold Program:

  • Income limits: $53,446-$63,446 (single) or $60,690-$70,690 (married)
  • Coverage: 50% off after $15 copay
  • Application: Same as PAAD

Foundation Assistance

Genentech Patient Foundation: For uninsured or underinsured patients with household incomes under approximately $75,000 (single) plus $25,000 for each additional person. Call 1-844-627-3887 for Patient Navigator assistance.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
No confirmed MS diagnosis Submit neurologist evaluation with MRI reports Diagnostic imaging, clinical notes, ICD-10 codes
Insufficient prior therapy trials Document step therapy compliance Prior authorization forms, pharmacy records, failure/intolerance notes
Missing safety screening Complete required labs and vaccinations HBV screening results, vaccination records, recent CBC
Non-preferred site of care Request site of care exception or switch providers Medical necessity letter, provider network verification
Combination therapy concerns Justify concurrent DMT use Clinical rationale, monitoring plan, drug interaction assessment
Tip: Keep detailed records of all prior MS treatments, including dates, dosages, and reasons for discontinuation. This documentation is crucial for overturning step therapy denials.

New Jersey Appeals Process

New Jersey offers robust appeal rights through the Independent Health Care Appeals Program (IHCAP), now managed by Maximus Federal Services.

Internal Appeals (Required First)

First Level: Submit within 180 days of initial denial

  • Use your BCBS plan's internal appeal form
  • Include medical records supporting medical necessity
  • Timeline: 30 days for standard, 72 hours for expedited

Second Level: If first appeal is denied

  • Timeline: 15 days for standard, 72 hours for expedited

External Review Through IHCAP

Eligibility: After completing internal appeals, you have 180 days to request external review.

Process:

  1. Submit directly to Maximus (no longer through NJ DOBI first)
  2. Preliminary review: 5 business days to confirm eligibility
  3. Full review: Up to 45 days for decision
  4. Expedited review: Completed within days if delay causes serious harm

Required documents:

  • Completed external appeal application
  • Copy of final internal denial letter
  • All relevant medical records
  • Physician support letter

Contact: Call 1-888-393-1062 for IHCAP-specific questions or 1-800-446-7467 for general DOBI consumer assistance.

Important: External review is free to you—insurers pay all costs. If the independent reviewers overturn the denial, your insurer must comply and provide coverage.

Step-by-Step Approval Strategy

Before You Start: Gather Documentation

  • Insurance card and member ID
  • Complete MS diagnosis records and MRI reports
  • List of all prior DMT treatments with dates and outcomes
  • Current lab results (CBC, liver function, HBV screening)
  • Vaccination records
  • Any previous denial letters or EOBs

Step 1: Verify Network and Coverage

Who: You or your clinic staff
Action: Confirm your neurologist and preferred infusion center are in-network
Timeline: Same day
Tools: BCBS member portal or call member services

Step 2: Prior Authorization Submission

Who: Your neurologist's office
Action: Submit PA request through MagellanRx (for Horizon) or appropriate PBM
Documents: Clinical notes, diagnosis codes, prior therapy records
Timeline: 72 hours for standard decision

Step 3: Address Any Requests for Additional Information

Who: Your clinic, with your help gathering records
Action: Respond to any PA follow-up requests within specified timeframe
Timeline: Usually 5-10 business days to respond

Step 4: If Approved, Coordinate Care

Who: You and your infusion center
Action: Schedule first infusion, apply for copay assistance
Timeline: Within 30 days of approval (varies by plan)

Step 5: If Denied, File Internal Appeal

Who: You, with clinic support
Action: Submit appeal with enhanced medical necessity letter
Timeline: Within 180 days of denial

Step 6: External Review if Needed

Who: You
Action: Apply to IHCAP through Maximus
Timeline: Within 180 days of final internal denial

Clinician Corner: Medical Necessity Documentation

Healthcare providers should include these elements in Ocrevus prior authorization and appeal letters:

Essential Components:

  • Specific MS phenotype with supporting MRI findings
  • Detailed history of prior DMT trials, including drug names, durations, and specific reasons for discontinuation
  • Current disability status and progression markers
  • Safety screening completion (HBV, vaccinations, baseline labs)
  • Treatment goals and monitoring plan

Helpful Clinical References:

  • FDA prescribing information for approved indications
  • American Academy of Neurology MS treatment guidelines
  • Plan-specific medical policies (available through provider portals)

When Counterforce Health assists with Ocrevus appeals, we focus on aligning clinical documentation with each plan's specific criteria while incorporating the strongest available evidence from FDA labeling, peer-reviewed studies, and specialty guidelines. This targeted approach significantly improves approval rates by addressing the exact basis for denial.

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in New Jersey?
Standard PA decisions are typically made within 72 hours. Expedited requests (when delay could cause serious harm) are processed within 24 hours.

What if Ocrevus is non-formulary on my plan?
You can request a formulary exception with documentation of medical necessity and why formulary alternatives are not appropriate. Include detailed records of prior treatment failures or contraindications.

Can I request an expedited appeal if my MS is progressing?
Yes. If waiting for a standard appeal timeline could cause serious harm to your health, you can request expedited review at both internal and external appeal levels.

Does step therapy apply if I've already failed DMTs outside New Jersey?
Treatment history from other states should be accepted if properly documented. Ensure your neurologist includes complete records of prior therapies, including dates, dosages, and outcomes.

What happens if my infusion center goes out of network?
Contact your BCBS plan immediately to request a continuity of care exception or help finding an in-network alternative. You may have 30-90 days of continued coverage at in-network rates.

Can my doctor request a peer-to-peer review?
Yes. Most BCBS plans allow prescribers to request a peer-to-peer discussion with the plan's medical director before or during the appeal process.

How do I know if I qualify for the Ocrevus copay program?
If you have commercial insurance (not Medicare, Medicaid, or other government coverage) and a prescription for Ocrevus, you likely qualify for up to $20,000 in annual assistance. Apply at ocrevuscopay.com.

What if I can't afford Ocrevus even with insurance?
Contact the Genentech Patient Foundation at 1-844-627-3887. They offer free drug programs for eligible uninsured and underinsured patients.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Treatment decisions should always be made in consultation with qualified healthcare providers. Insurance coverage varies by plan and individual circumstances.

For personalized assistance with complex Ocrevus coverage challenges, Counterforce Health helps patients and providers navigate insurance denials by creating evidence-backed appeals tailored to each plan's specific requirements. Our platform transforms denial letters into targeted rebuttals that align with payer policies while incorporating the strongest available clinical evidence.

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