By Counterforce Health Team in Ocrevus (ocrelizumab) —

Getting Ocrevus (Ocrelizumab) Covered by Blue Cross Blue Shield in Virginia: PA Requirements, Appeals, and Success Strategies

Answer Box: Quick Path to Coverage

To get Ocrevus (ocrelizumab) covered by Blue Cross Blue Shield in Virginia: Complete the specific Ocrevus PA form with all required checkboxes, including confirmed MS diagnosis, hepatitis B screening results, and step therapy documentation. Fax to 844-512-7020 with supporting MRI reports and clinical notes. If denied, you have 180 days for internal appeals and 120 days for Virginia's external review process through the State Corporation Commission. Start by downloading the Anthem Virginia Ocrevus PA form today.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Documentation Packet Essentials
  5. Submission Process
  6. Common Denial Reasons & Fixes
  7. Appeals Process in Virginia
  8. Cost Assistance Options
  9. When to Escalate
  10. Frequently Asked Questions

Who Should Use This Guide

This guide helps Virginia patients with multiple sclerosis (MS) navigate Blue Cross Blue Shield's prior authorization requirements for Ocrevus (ocrelizumab), a B-cell depleting therapy administered every six months. You'll need this if:

  • Your neurologist has prescribed Ocrevus for relapsing MS (RRMS, active SPMS, CIS) or primary progressive MS
  • You have Anthem Blue Cross Blue Shield Virginia coverage (including HealthKeepers Plus Medicaid)
  • You're facing a prior authorization request or denial
  • You need to document step therapy failures or contraindications

Expected outcome: With complete documentation, most medically appropriate Ocrevus requests receive approval within 5-14 business days. Denials often stem from missing documentation rather than medical necessity concerns.

Member & Plan Basics

Coverage Verification

Before starting the PA process:

  • Confirm active Blue Cross Blue Shield Virginia coverage through the member portal
  • Verify Ocrevus requires prior authorization (effective April 1, 2025 for both IV and subcutaneous formulations)
  • Check your deductible status and specialty drug tier placement
  • Ensure your prescribing neurologist is in-network

Plan Types Covered

This process applies to:

  • Anthem Blue Cross Blue Shield Virginia commercial plans
  • HealthKeepers Plus Medicaid managed care
  • Some self-funded employer plans (verify with HR)

Clinical Criteria Requirements

Anthem Virginia requires all of the following criteria with supporting documentation:

Universal Requirements

  • Age: Member ≥18 years old
  • Hepatitis B screening: Negative HBsAg and anti-HBV core antibody before treatment
  • Baseline immunoglobulin levels: Assessed prior to initiation
  • Vaccination status: No live/live-attenuated vaccines within 4 weeks
  • Infection screening: No active infections at treatment start
  • Monotherapy use: Ocrevus used alone, not with other DMTs
  • Dosing interval: No ocrelizumab or ublituximab within past 5 months

MS Diagnosis Requirements

MS Type Specific Criteria
Relapsing MS (RRMS, active SPMS, CIS) McDonald criteria met: ≥1 relapse in prior 2 years OR gadolinium-enhancing/new T2 lesions; ≥1 T2-hyperintense lesion in ≥2 CNS areas (periventricular, cortical/juxtacortical, infratentorial, spinal cord) OR CSF oligoclonal bands
Primary Progressive MS Member <65 years; EDSS ≤6.5; progressive disability from onset

Step Therapy Considerations

While Anthem's Ocrevus form doesn't explicitly require step therapy failures, many plans expect documentation of:

  • Prior disease-modifying therapy trials and outcomes
  • Reasons for switching (inadequate response, intolerance, contraindications)
  • Clinical rationale for high-efficacy therapy selection

Documentation Packet Essentials

Required Clinical Documents

  1. MRI reports showing MS lesions and activity
  2. Laboratory results: HBV panel, immunoglobulin levels, CBC with differential
  3. Clinical notes documenting MS phenotype, EDSS score, relapse history
  4. Prior therapy records (if applicable): medication names, dates, outcomes, discontinuation reasons
  5. Vaccination records confirming no recent live vaccines

Medical Necessity Letter Components

Your neurologist should include:

  • Patient demographics: Name, DOB, insurance ID, diagnosis (ICD-10: G35.A for RRMS, G35.B0-B2 for PPMS, G35.C0-C2 for SPMS)
  • MS phenotype confirmation: Clinical and MRI evidence meeting diagnostic criteria
  • Treatment rationale: Why Ocrevus is medically necessary for this patient
  • Monitoring plan: Infusion protocols, safety assessments, response evaluation
  • Supporting evidence: FDA labeling, clinical trial data, MS society guidelines
From our advocates: We've seen faster approvals when neurologists include specific MRI dates and lesion counts in their letters, along with clear statements about why first-line therapies aren't appropriate. A detailed three-paragraph rationale often works better than a brief checkbox form.

Submission Process

Step-by-Step Submission

  1. Download the correct form: Use the Anthem Virginia Ocrevus PA form (updated July 2024)
  2. Complete all checkboxes: Incomplete forms cause automatic delays
  3. Attach all documentation: MRI reports, labs, clinical notes, prior therapy records
  4. Provider signature required: Must include prescriber signature and date
  5. Submit via fax: 844-512-7020 (confirm current number with provider services)
  6. Keep confirmation: Save fax confirmation and submission date

Processing Timeline

  • Standard review: 5-14 business days from complete submission
  • Expedited review: Available for urgent medical situations
  • Incomplete submissions: Expect requests for additional information

Tracking Your Request

  • Call Provider Services at 800-901-0020 for status updates
  • Use provider portal for real-time tracking (when available)
  • Document all interactions with reference numbers

Common Denial Reasons & Fixes

Denial Reason Required Fix Supporting Documents
Incomplete HBV screening Submit full hepatitis B panel HBsAg, anti-HBc, anti-HBs results
Missing vaccination verification Provide immunization records Documentation of no live vaccines ×4 weeks
Insufficient MS documentation Submit comprehensive MRI reports Brain/spine MRI with gadolinium, radiologist interpretation
Lack of step therapy justification Document prior DMT trials/contraindications Medication history, adverse event reports, clinical rationale
Dosing concerns Clarify administration schedule Infusion protocol, monitoring plan, site of care

Appeals Process in Virginia

Internal Appeals (Blue Cross Blue Shield)

  • Timeline: 180 days from denial notice to file
  • Process: Submit written appeal with additional documentation
  • Decision timeframe: 30 days for standard, 72 hours for expedited
  • Required elements: Member information, denial details, clinical justification

External Review (Virginia SCC)

If internal appeals fail, Virginia offers robust external review:

  1. Eligibility: Complete internal appeals first
  2. Timeline: 120 days from final internal denial to file Form 216-A
  3. Process: Independent review by board-certified specialists
  4. Decision timeline: 45 days standard, 72 hours expedited
  5. Contact: Virginia Bureau of Insurance at 1-877-310-6560

The external review decision is binding on Blue Cross Blue Shield and often overturns wrongful denials based on medical evidence.

Cost Assistance Options

Manufacturer Support

  • Genentech Patient Foundation: Income-based assistance for eligible patients
  • Ocrevus Co-pay Program: May reduce out-of-pocket costs for commercially insured patients
  • Contact: Visit Genentech Access Solutions or call patient support

State and Federal Programs

  • Virginia Medicaid: Covers Ocrevus with prior authorization
  • Medicare Part B: Age 65+ or disability coverage
  • 340B programs: Discounted pricing at qualifying healthcare facilities

Specialty Pharmacy Support

Many specialty pharmacies offer:

  • Prior authorization assistance
  • Appeals support
  • Financial counseling
  • Medication delivery coordination

When to Escalate

Contact these resources when standard appeals aren't working:

Virginia Insurance Regulators

  • Bureau of Insurance: 1-877-310-6560 for external review guidance
  • Managed Care Ombudsman: Informal resolution assistance through SCC
  • Consumer Services: Help understanding appeal rights and procedures

Professional Advocacy

  • National MS Society: Patient advocacy and appeals assistance
  • Patient navigator programs: Many MS centers offer dedicated support staff
  • Counterforce Health: Specialized platform that helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements.

Frequently Asked Questions

Q: How long does Blue Cross Blue Shield PA take in Virginia? A: Standard review takes 5-14 business days from complete submission. Expedited reviews are available for urgent situations with 72-hour turnaround.

Q: What if Ocrevus isn't on my formulary? A: Submit a formulary exception request with medical necessity documentation. Blue Cross Blue Shield must review non-formulary requests within 72 hours.

Q: Can I appeal if I live in Virginia but have coverage from another state? A: Virginia's external review process applies to Virginia-issued plans. For out-of-state coverage, check your plan's appeals procedures or contact Virginia Bureau of Insurance for guidance.

Q: Does step therapy always apply for Ocrevus? A: Requirements vary by plan. While Anthem's current form doesn't mandate specific step therapy, documenting prior DMT history strengthens your case.

Q: What happens if my appeal is denied? A: You can proceed to Virginia's external review process, which is binding on the insurer. The independent medical reviewers often overturn denials when clinical evidence supports coverage.

Q: Can I get expedited review for MS relapses? A: Yes. If your neurologist certifies that waiting could seriously jeopardize your health, Virginia offers expedited external review within 72 hours.

Q: Are there special provisions for PPMS patients? A: Ocrevus is the first FDA-approved treatment for PPMS. Strong clinical evidence supports coverage, but ensure documentation includes age <65 and EDSS ≤6.5 criteria.

Q: How do I track my appeal status? A: Use Blue Cross Blue Shield's provider portal, call member services, or contact Virginia Bureau of Insurance for external reviews. Always document reference numbers and interaction dates.

Disclaimer: This information is for educational purposes and doesn't constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult your healthcare provider and insurance plan directly for personalized guidance.

For additional help with complex denials and appeals, Counterforce Health offers specialized support in turning insurance denials into successful appeals through evidence-based advocacy aligned with payer-specific requirements.

Sources & Further Reading

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