By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Aetna CVS Health in Illinois: Timeline, Forms & Appeals

Answer Box: Get Ocrevus Covered by Aetna CVS Health in Illinois

Aetna requires prior authorization for Ocrevus (ocrelizumab), which typically takes 24-72 hours for standard review. Your neurologist must submit the precertification through Aetna's Availity portal or by calling 1-866-752-7021. If denied, Illinois residents have 180 days for internal appeals and must request external review within 4 months of the final denial. Start the process 6-8 weeks before your scheduled infusion to ensure coverage.

Table of Contents

  1. What Affects Ocrevus Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-3 Days)
  4. Decision Window and Outcomes
  5. If Denied: Illinois Appeal Process
  6. Renewal Cycles and Maintenance
  7. Timeline Visual and Milestones
  8. Time-Saving Tips for Faster Approval

What Affects Ocrevus Approval Timing

Several factors influence how quickly Aetna CVS Health processes your Ocrevus prior authorization in Illinois:

Benefit Type Impact: Commercial plans typically process faster than Medicare Advantage Part B, which requires additional documentation. Aetna's Medicare Part B process involves different contact numbers (1-866-503-0857) and fax lines (1-844-268-7263).

Clinical Complexity: New diagnoses require more extensive documentation than established patients. Aetna considers Ocrevus medically necessary for three specific indications: relapsing forms of MS, clinically isolated syndrome (CIS), and primary progressive MS, as outlined in their clinical policy bulletin.

Documentation Completeness: Missing neurologist consultation notes, incomplete MRI reports, or unclear prior therapy history can delay approval by 3-7 days while additional information is requested.

Note: Illinois residents benefit from strong state protections. If Aetna fails to respond within required timeframes, you may proceed directly to external review without exhausting internal appeals.

Pre-Submission Preparation (0-2 Days)

Gathering complete documentation upfront prevents delays and additional information requests.

Essential Documentation Checklist

Clinical Requirements:

  • Current neurologist consultation notes (within 6 months)
  • MRI reports showing MS lesions or disease activity
  • Confirmed MS diagnosis with specific phenotype (RRMS, SPMS with relapses, PPMS, or CIS)
  • Documentation that no other disease-modifying therapies are being used concurrently

Administrative Details:

  • Member ID and group number from insurance card
  • Prescribing neurologist's NPI and contact information
  • Proposed infusion site and administration plan
  • ICD-10 codes for specific MS diagnosis

Prior Therapy Documentation (if applicable):

  • Records of previous DMT trials and reasons for discontinuation
  • Evidence of treatment failures or intolerances
  • Vaccination history and hepatitis B screening results

Counterforce Health specializes in helping patients and clinicians compile this evidence efficiently, turning insurance denials into targeted appeals by identifying exactly what documentation payers require for approval.

Submission to Initial Review (1-3 Days)

Once your neurologist submits the complete prior authorization request, Aetna's review process begins.

Submission Methods and Timelines

Electronic Submission (Fastest):

  • Availity portal for most efficient processing
  • Typically reviewed within 24-48 hours
  • Real-time status updates available

Phone and Fax Options:

  • Commercial: 1-866-752-7021 (phone), 1-888-267-3277 (fax)
  • Medicare Part B: 1-866-503-0857 (phone), 1-844-268-7263 (fax)
  • Processing may take 48-72 hours

What Reviewers Check First

Aetna's initial review focuses on:

  1. Prescriber Qualification: Must be prescribed by or in consultation with a neurologist
  2. Indication Match: Diagnosis must align with FDA-approved indications
  3. Concurrent Therapy: Verification that no other DMTs are being used simultaneously
  4. Site of Care: Commercial plans may have site-of-care restrictions under utilization management policies
Tip: More than 95% of eligible prior authorizations are approved within 24 hours when complete documentation is provided upfront.

Decision Window and Outcomes

Standard Review Timelines

Routine Decisions: 24-72 hours for complete submissions Expedited Review: Available when delay would significantly impact health, with decisions within 24-36 hours Additional Information Requests: If incomplete, Aetna may request additional documentation, extending the timeline by 3-7 days

Reading Your Approval Letter

Approved authorizations will specify:

  • Approved indication and ICD-10 codes
  • Authorized quantity and frequency (typically every 6 months)
  • Approved infusion site or pharmacy
  • Authorization expiration date
  • Any special conditions or monitoring requirements

If Denied: Illinois Appeal Process

Illinois provides robust patient protections for insurance appeals, with specific timelines that differ from other states.

Internal Appeals with Aetna

Level One Appeal: You have 180 calendar days from receipt of the denial to file your first internal appeal. For urgent care claims, Aetna must respond within 36 hours. Pre-service claims receive decisions within 15 business days.

Required Documentation:

  • Copy of denial letter
  • Member name and employer information
  • Detailed reasons for appeal
  • Supporting medical records and clinical notes

Expedited Appeals: Available when standard timing would jeopardize your health. Submit evidence that delay would significantly increase health risks.

Illinois External Review Process

If internal appeals fail, Illinois law guarantees independent external review through the Health Carrier External Review Act.

Critical Deadline: You must request external review within 4 months of receiving Aetna's final adverse determination. This is longer than the 30-day window mentioned in some other states.

Process Overview:

  1. File request with Illinois Department of Insurance
  2. Independent Review Organization (IRO) assigned
  3. Board-certified physician reviewer with MS expertise
  4. Decision within 5 business days of receiving all materials
  5. Binding decision - if overturned, Aetna must provide coverage

Illinois-Specific Resources:

When navigating complex appeals, Counterforce Health helps identify the specific denial basis and drafts point-by-point rebuttals aligned to Aetna's own coverage criteria, increasing the likelihood of successful appeals.

Renewal Cycles and Maintenance

Ocrevus typically requires reauthorization every 6-12 months, depending on your specific plan.

Renewal Documentation

Established Patients Need:

  • Updated neurologist notes showing disease stability or improvement
  • Recent MRI reports (ideally within 12 months)
  • Treatment history and infusion dates
  • Confirmation of continued medical necessity

Timeline for Renewals: Start the renewal process 6-8 weeks before your scheduled infusion to prevent treatment delays.

What Speeds Renewals

  • Consistent treatment history with documented stability
  • Complete medical records from the same neurologist
  • No concurrent use of other DMTs
  • Clear documentation of ongoing medical necessity

Timeline Visual and Milestones

Milestone Timeline Key Actions Illinois-Specific Notes
Pre-submission 0-2 days Gather documentation, verify neurologist consultation Start 6-8 weeks before needed infusion
Initial submission Day 1 Submit via Availity portal or phone Use expedited process if urgent
Under review 1-3 days Aetna reviews for completeness 95% approved within 24 hours if complete
Decision issued 2-5 days Approval or denial notification If no response in 30 days, may proceed to external review
If denied - Internal appeal 180 days to file Submit Level One appeal 15 business days for pre-service decision
External review 4 months to file File with Illinois DOI 5 business days for IRO decision

Time-Saving Tips for Faster Approval

Portal Usage Best Practices

  • Use Availity Portal: Electronic submissions process fastest
  • Track Status Online: Monitor progress through Aetna's secure member portal
  • Bundle Documentation: Submit all required documents simultaneously

Direct Specialty Routing

  • Ensure your neurologist submits directly rather than through primary care
  • Use specialty pharmacy networks when possible for streamlined processing
  • Consider established infusion centers with existing Aetna relationships

Common Acceleration Strategies

  1. Pre-verify Benefits: Confirm coverage details before submission
  2. Use Standard Forms: Aetna's official precertification forms process faster than custom letters
  3. Include Peer Review Request: For complex cases, request peer-to-peer review with an Aetna medical director
From our advocates: A composite tip from our experience helping patients navigate approvals: "The most successful Ocrevus approvals we've seen include three key elements upfront: clear neurologist documentation of MS phenotype, evidence of appropriate hepatitis B screening, and explicit confirmation that no other DMTs are being used. When these are included in the initial submission, approval typically happens within 24-48 hours."

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Aetna precertification list 2025 Precert List
Neurologist Requirement Must prescribe or consult Clinical policy Aetna Policy 0264
No Concurrent DMTs Cannot use with other MS drugs Policy exclusions Clinical Policy
Approved Indications RRMS, SPMS with relapses, PPMS, CIS FDA labeling Aetna Coverage Criteria

Frequently Asked Questions

How long does Aetna prior authorization take for Ocrevus in Illinois? Standard review takes 24-72 hours for complete submissions. Expedited review is available within 24-36 hours when delay would jeopardize health.

What if Ocrevus is non-formulary on my plan? Submit a formulary exception request with documentation of medical necessity. Include evidence of prior therapy failures and neurologist support for Ocrevus specifically.

Can I request an expedited appeal in Illinois? Yes, expedited appeals are available when standard timing would significantly increase health risks. Aetna must respond within 36 hours for urgent care appeals.

Does step therapy apply if I've been on Ocrevus before? Generally no. Patients established on Ocrevus within the past 365 days are typically exempt from step therapy requirements.

What happens if Aetna doesn't respond within required timeframes? Illinois law allows you to proceed directly to external review if Aetna fails to meet decision deadlines, without exhausting internal appeals.

Who can I contact for help with appeals in Illinois? Illinois Department of Insurance: 877-527-9431, or Illinois Attorney General Health Care Helpline: 1-877-305-5145.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for decisions about your specific situation. For additional help with complex coverage issues, Counterforce Health provides specialized assistance in turning insurance denials into successful appeals through evidence-backed documentation and payer-specific strategies.

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