By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (ocrelizumab) Covered by Aetna (CVS Health) in Michigan: Complete Guide to Prior Authorization and Appeals

Quick Answer: Getting Ocrevus Covered by Aetna in Michigan

Aetna (CVS Health) requires prior authorization for Ocrevus (ocrelizumab) in Michigan. Submit the Ocrevus Precertification Request form with MS diagnosis confirmation, neurologist prescription, and documentation of disease progression or relapse history. If denied, you have 180 days to appeal internally, then 127 days to file for Michigan's binding external review through DIFS. For urgent situations, expedited external review decisions come within 72 hours. Start by contacting your neurologist to initiate the prior authorization process today.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all new and renewal requests Aetna Precertification List Aetna Policy
Diagnosis Relapsing MS, PPMS, or CIS with ICD-10 codes FDA labeling requirements Aetna Clinical Policy
Prescriber Must be neurologist or in consultation with one Specialty requirement Aetna Policy
Formulary Tier Specialty tier (high copay/coinsurance) Plan-specific drug guide Aetna Formulary
Annual Renewal Required every 12 months with clinical updates Ongoing monitoring needed Aetna Policy
Appeals Deadline 127 days for Michigan external review State-specific timeline Michigan DIFS

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: You and your neurologist
What: Insurance card, complete MS diagnosis with ICD-10 codes, prior treatment history, current MRI results, EDSS scores
Timeline: 1-2 days

2. Complete Prior Authorization Form

Who: Your neurologist's office
What: Aetna Ocrevus Precertification Request form
How: Submit electronically via Availity portal (preferred) or fax
Timeline: Same day completion

3. Submit Clinical Documentation

Who: Your neurologist
What: Chart notes showing MS progression, failed prior therapies, contraindications to alternatives
Timeline: Include with PA form

4. Follow Up on Decision

Who: You or your clinic
What: Check authorization status after 5-7 business days
Contact: Aetna at 1-888-632-3862 (commercial) or 1-800-624-0756 (Medicare)

5. If Approved, Schedule Infusion

Who: You and CVS Specialty Pharmacy
What: Coordinate delivery and infusion scheduling
Timeline: 7-10 days for specialty pharmacy processing

6. If Denied, File Internal Appeal

Who: You or your neurologist
What: Appeal letter with additional clinical evidence
Timeline: Must file within 180 days of denial

7. Consider External Review if Needed

Who: You
What: File with Michigan DIFS if internal appeal fails
Timeline: Within 127 days of final internal denial

Understanding Aetna's Ocrevus Coverage Criteria

Aetna covers Ocrevus for FDA-approved indications when specific clinical criteria are met. According to Aetna's Clinical Policy Bulletin, coverage requires:

Approved Diagnoses:

  • Relapsing forms of multiple sclerosis (including RRMS and active SPMS)
  • Primary progressive multiple sclerosis (PPMS)
  • Clinically isolated syndrome (CIS)

Clinical Requirements:

  • Confirmed MS diagnosis by a neurologist
  • Appropriate ICD-10 diagnostic codes
  • Documentation of disease activity or progression
  • Pre-infusion safety screening (HBV, vaccinations)
  • No concurrent use of other MS disease-modifying therapies
Note: Ampyra and Nuedexta are not considered disease-modifying therapies and can be used concurrently with Ocrevus.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide evidence of MS progression or relapse history Recent MRI showing new lesions, EDSS progression, relapse documentation
"No trial of preferred alternatives" Document failures/contraindications to first-line therapies Chart notes showing intolerance, lack of efficacy, or contraindications
"Experimental/investigational" Cite FDA approval and clinical guidelines FDA labeling, AAN guidelines
"Prescriber not qualified" Confirm neurologist involvement Referral letter or co-signature from neurologist
"Missing safety screening" Complete required tests HBV screening results, vaccination records

Appeals Process: Your Rights in Michigan

Internal Appeals with Aetna

  • First Level: Standard internal appeal within 180 days of denial
  • Timeline: 30-45 days for standard decisions, 72 hours for urgent/expedited
  • How to File: Call member services or submit written appeal
  • Required: Denial letter, additional clinical evidence, prescriber support

Michigan External Review

If Aetna upholds the denial, Michigan residents have additional rights under the Patient's Right to Independent Review Act.

Key Features:

  • Deadline: 127 days from final internal denial
  • Cost: Free to patients
  • Timeline: 60 days for standard review, 72 hours for expedited
  • Decision: Binding on Aetna
  • Contact: Michigan DIFS at 877-999-6442

Expedited External Review: Available when delay would "seriously jeopardize" your health. Requires physician letter documenting medical urgency.

From our advocates: We've seen Michigan patients successfully overturn Aetna denials for Ocrevus by providing comprehensive documentation of failed prior therapies and clear evidence of MS progression. The key is thorough preparation before filing—gather all MRI reports, treatment histories, and have your neurologist write a detailed medical necessity letter addressing each denial reason specifically.

Medical Necessity Documentation Guide

Essential Elements for Your Neurologist to Include:

Clinical History:

  • Specific MS phenotype (RRMS, SPMS, PPMS)
  • Date of diagnosis and diagnostic criteria met
  • Current EDSS score and progression over time
  • Recent relapse history with dates and symptoms

Prior Treatment Documentation:

  • Previous disease-modifying therapies tried
  • Duration of each treatment
  • Reasons for discontinuation (lack of efficacy, intolerance, contraindications)
  • Specific adverse events or treatment failures

Current Disease Activity:

  • Recent MRI findings (new or enlarging T2 lesions, gadolinium-enhancing lesions)
  • Clinical evidence of progression
  • Functional impact on daily activities

Treatment Rationale:

  • Why Ocrevus is appropriate for this patient
  • Expected benefits based on clinical trials
  • Monitoring plan for safety and efficacy

Counterforce Health helps patients and clinicians prepare comprehensive appeals by analyzing denial letters and creating targeted, evidence-backed responses that align with each payer's specific requirements.

Costs and Financial Assistance

Insurance Coverage

  • Specialty Tier: Expect higher copays/coinsurance (typically 20-40% after deductible)
  • Site of Care: May be covered differently at hospital outpatient vs. physician office
  • Annual Deductible: Often applies before coverage begins

Financial Assistance Options

  • Genentech Patient Foundation: Income-based assistance programs
  • Ocrevus Co-pay Program: May reduce out-of-pocket costs for eligible patients
  • Michigan Prescription Drug Assistance: State programs for qualifying residents
Tip: Contact CVS Specialty Pharmacy at 1-800-237-2767 to discuss payment options and assistance program enrollment.

Frequently Asked Questions

How long does Aetna prior authorization take for Ocrevus in Michigan? Standard decisions typically take 5-7 business days. Urgent requests may be processed within 72 hours if medical urgency is documented.

What if my Ocrevus prescription lapses during renewal? Contact CVS Caremark Specialty immediately at 1-800-237-2767 to request an emergency fill or bridge supply while renewal is processed.

Can I appeal if I'm on a Medicare Advantage plan? Yes, Medicare Advantage members have the same appeal rights, including Michigan's external review process through DIFS.

Does step therapy apply to Ocrevus renewals? Generally not for existing patients, but new patients may need to try preferred alternatives first unless contraindicated.

What counts as "expedited" for appeals? Situations where delay would seriously jeopardize your health, such as preventing MS relapses that could cause permanent disability.

How often does Aetna require Ocrevus reauthorization? Annual renewal is required with documentation of continued medical necessity and treatment response.

When Coverage Gaps Occur

If your Ocrevus coverage lapses during renewal or appeal:

  1. Contact CVS Specialty immediately for emergency fill options
  2. Ask your neurologist to document medical urgency for expedited processing
  3. Consider temporary alternatives your doctor may recommend
  4. Track all delays for potential complaint filing with Michigan DIFS

For urgent situations, Michigan's expedited external review can provide binding decisions within 72 hours when physician documentation supports the urgency.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance company for personalized guidance. Counterforce Health provides tools and resources to help navigate the prior authorization and appeals process, but outcomes cannot be guaranteed.

For immediate assistance with Michigan insurance appeals, contact Michigan DIFS at 877-999-6442 or visit their consumer assistance webpage.

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