By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus Covered by Blue Cross Blue Shield in Texas: Complete Prior Authorization Guide

Answer Box: Getting Ocrevus Covered by BCBS Texas

Ocrevus (ocrelizumab) requires prior authorization from Blue Cross Blue Shield of Texas for most plans. The fastest path to approval: (1) Confirm your plan type and specialty pharmacy network, (2) Submit PA request with complete MS diagnosis documentation and prior therapy history, and (3) Allow 30 days for standard review or request expedited processing if urgent. Start today by calling the PA number on your member ID card or having your provider access the BCBS Texas provider portal.

Table of Contents

If you're living with multiple sclerosis in Texas and your doctor has prescribed Ocrevus (ocrelizumab), getting insurance approval can feel overwhelming. This comprehensive guide walks you through exactly how to navigate Blue Cross Blue Shield of Texas's prior authorization process, from initial submission to appeals if needed.

Ocrevus is a breakthrough medication for both relapsing and primary progressive MS, but its high cost means insurers scrutinize every request. The good news? With proper documentation and persistence, most medically appropriate requests eventually get approved.

Before You Start: Plan Verification

Check Your Specific BCBS Texas Plan

Not all Blue Cross Blue Shield plans in Texas have identical requirements. HealthSelect of Texas plans eliminated prior authorization requirements as of September 1, 2024, but still require a primary care physician referral to see specialists in-network.

For all other BCBS Texas plans (most individual and employer group plans), prior authorization remains mandatory for Ocrevus.

Action steps:

  • Look at your member ID card for your specific plan name
  • Call the customer service number on your card to confirm PA requirements
  • Verify that your neurologist is in-network

Medical vs. Pharmacy Benefit

Ocrevus is administered by IV infusion, so it's covered under your medical benefit, not pharmacy benefit. This means:

  • Your doctor orders it from a specialty pharmacy
  • It's administered in a clinical setting (office, infusion center, or hospital)
  • You'll pay medical copays/deductibles, not pharmacy copays

What You Need to Gather

Essential Documentation

For your diagnosis:

  • ICD-10 code G35 (Multiple sclerosis)
  • Specific MS type: relapsing-remitting (RRMS) or primary progressive (PPMS)
  • Recent MRI reports showing MS lesions
  • Neurological examination notes

For prior therapies:

  • Complete list of previous MS medications tried
  • Dates of treatment and duration
  • Reasons for discontinuation (lack of efficacy, side effects, contraindications)
  • Documentation of inadequate response or intolerance

Clinical support:

  • Letter of medical necessity from your neurologist
  • Recent lab work (hepatitis B screening required)
  • Vaccination history
  • Current disability status and functional assessments

Required Codes for Billing

Code Type Code Description
ICD-10 G35 Multiple sclerosis
HCPCS J2351 Ocrelizumab, 1 mg
NDC 50242-150-01 300 mg vial
CPT 96413, 96415 IV infusion administration

Step-by-Step: Fastest Path to Approval

1. Provider Submits Prior Authorization Request

Who does it: Your neurologist's office
Timeline: Allow 2-3 business days for submission
How: Via BCBS Texas provider portal or fax

2. BCBS Reviews Medical Necessity

Timeline: 30 days for standard review, 72 hours for expedited
What they evaluate: Diagnosis confirmation, prior therapy documentation, clinical guidelines alignment

3. Decision Notification

How you'll know: Written notice to both patient and provider
If approved: Authorization number provided with validity period
If denied: Specific denial reason codes and appeal rights included

4. Specialty Pharmacy Coordination

Who handles: Your provider's office coordinates with BCBS-contracted specialty pharmacy
Timeline: 1-2 weeks for drug delivery to infusion site
Your role: Confirm insurance information and delivery details

5. Schedule Infusion

Timeline: Once drug arrives at infusion center
Preparation: Complete hepatitis B screening if not already done
Duration: Initial infusions take 3.5+ hours; subsequent infusions about 2.5 hours

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for most BCBS TX plans BCBS Texas PA codes list
Medical Necessity FDA-approved MS indication BCBS Texas medical policy RX501.085
Step Therapy May require trial of other DMTs first Plan-specific; check formulary
Specialty Pharmacy Must use BCBS-contracted pharmacy BCBS Texas specialty pharmacy info
Provider Network Neurologist must be in-network Provider directory on member portal

Common Denial Reasons & How to Fix Them

Incomplete Documentation

The problem: Missing prior therapy history or inadequate clinical notes
The fix: Submit comprehensive treatment timeline with specific dates, dosages, and outcomes

Step Therapy Not Met

The problem: Plan requires trial of less expensive MS drugs first
The fix: Document contraindications to required medications or submit step therapy exception request with clinical justification

"Not Medically Necessary"

The problem: Insurer questions whether Ocrevus is appropriate
The fix: Request peer-to-peer review; provide guidelines from American Academy of Neurology supporting treatment choice

Administrative Errors

The problem: Wrong codes, forms, or submission pathway
The fix: Verify all HCPCS codes, NDC numbers, and ensure submission through correct portal

From our advocates: We've seen cases where a simple step therapy exception request, supported by documentation that first-line therapies caused liver enzyme elevation, turned a denial into approval within two weeks. The key was having the neurologist clearly explain why bypassing typical protocols was medically necessary for this specific patient.

Appeals Process for BCBS Texas

Internal Appeal (First Level)

Deadline: 180 days from denial notice
How to file: Call 1-888-657-6061 or mail to:

Blue Cross and Blue Shield of Texas
Attn: Complaints and Appeals Department
P.O. Box 660717
Dallas, TX 75266-0717

Timeline: 30 days for standard appeals, 72 hours for expedited
What to include: Original denial letter, additional clinical documentation, provider letter supporting medical necessity

Peer-to-Peer Review

Request this immediately after denial. Your neurologist speaks directly with the BCBS medical director to discuss your case. Success tips:

  • Have your doctor prepare talking points about MS progression and treatment history
  • Reference specific clinical guidelines supporting Ocrevus use
  • Emphasize unique patient factors that make standard protocols inappropriate

External Review (Independent Review Organization)

When to request: After internal appeal denial
Deadline: 120 days from final internal denial
Who decides: Independent medical experts not employed by BCBS
Timeline: 20 days for standard, 72 hours for expedited
Cost: Free to you (BCBS pays the IRO)

Texas law requires BCBS to provide external review for medical necessity denials. The independent reviewers often overturn insurer decisions when clinical evidence supports treatment.

For assistance with the external review process, contact the Texas Department of Insurance at 1-800-252-3439.

Costs & Patient Assistance

Manufacturer Support

Ocrevus Access Solutions offers:

  • Benefits investigation and prior authorization support
  • Copay assistance (up to $5,000 per year for eligible patients)
  • Financial hardship programs

Additional Resources

  • Genentech Patient Foundation: Provides free medication for qualifying uninsured patients
  • National MS Society: Financial assistance and advocacy support
  • Patient Advocate Foundation: Helps navigate insurance appeals

When cost is a barrier, Counterforce Health helps patients and providers build stronger appeals by analyzing denial letters and crafting evidence-based rebuttals that address insurers' specific concerns. Their platform streamlines the appeals process and improves approval rates for complex specialty medications.

FAQ: Your Top Questions Answered

How long does BCBS Texas prior authorization take?
Standard review: 30 days. Expedited review (when delay would jeopardize health): 72 hours. Processing can be faster with complete documentation.

What if Ocrevus isn't on my formulary?
Request a formulary exception. Your doctor must demonstrate medical necessity and explain why covered alternatives aren't appropriate.

Can I get Ocrevus if I haven't tried other MS drugs?
Depends on your specific plan's step therapy requirements. Some allow Ocrevus as first-line therapy for aggressive MS; others require trying interferons or other DMTs first.

What happens if I switch BCBS plans?
You'll likely need a new prior authorization. Start the process 30-60 days before your plan change takes effect.

Does BCBS cover both IV and subcutaneous Ocrevus?
Coverage varies by plan. The newer subcutaneous formulation (Ocrevus Zunovo) may require separate authorization.

Can I appeal if my doctor isn't in-network?
Yes, but it's more complex. You may need to prove that no in-network specialists can provide appropriate care, or pay higher out-of-network costs.

When to Contact Texas Insurance Regulators

If BCBS Texas violates appeal timelines or denies coverage inappropriately, you can file a complaint with the Texas Department of Insurance:

Phone: 1-800-252-3439
Online: TDI consumer complaint portal
Mail: Texas Department of Insurance, Consumer Protection, P.O. Box 149104, Austin, TX 78714-9104

The Texas Office of Public Insurance Counsel (OPIC) also provides free assistance: 1-877-611-6742.

Checklist: Before You Submit

  • Confirmed PA requirement for your specific BCBS Texas plan
  • Verified neurologist is in-network
  • Gathered complete prior therapy documentation
  • Obtained hepatitis B screening results
  • Provider has letter of medical necessity ready
  • Identified BCBS-contracted specialty pharmacy
  • Documented current MS symptoms and disability status
  • Prepared step therapy exception justification (if needed)

Getting Ocrevus approved by Blue Cross Blue Shield of Texas requires patience and thorough documentation, but don't let the process discourage you from pursuing the treatment your doctor recommends. With proper preparation and persistence through the appeals process when necessary, most medically appropriate requests ultimately succeed.

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for guidance specific to your situation.

Sources & Further Reading

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