By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (ocrelizumab) Covered by Aetna (CVS Health) in Ohio: Complete Appeals Guide with Forms and Scripts

Quick Answer: Getting Ocrevus Covered by Aetna in Ohio

Aetna requires prior authorization for Ocrevus but doesn't mandate step therapy for FDA-approved MS indications. Submit complete clinical documentation including MS diagnosis confirmation, prior therapy history, and hepatitis B screening. If denied, request a peer-to-peer review immediately, then file internal appeals within 60 days. Ohio residents get external review through the state Department of Insurance within 180 days of final denial.

First step today: Download Aetna's Ocrevus precertification form and gather your MS diagnosis documentation, prior therapy records, and current lab results.

Table of Contents

Coverage Requirements at a Glance

Requirement Details Where to Find It
Prior Authorization Always required Aetna precertification list
Step Therapy Not required for FDA-approved MS indications Aetna clinical policy
Formulary Status Covered with PA CVS Caremark formulary
Diagnosis Codes G35 (Multiple Sclerosis) ICD-10 coding
Site of Care Office, infusion center, or hospital Aetna precert form
Age Restrictions None for approved indications FDA labeling

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Patient and clinic staff
Timeline: 1-2 days
Documents needed:

  • Insurance card and policy details
  • MRI reports confirming MS diagnosis
  • Complete list of prior disease-modifying therapies with dates and outcomes
  • Hepatitis B screening results
  • Current neurological assessment

2. Complete Aetna's Precertification Form

Who: Prescribing physician
Timeline: 30 minutes
Download the Aetna Ocrevus precertification form and include:

  • Primary diagnosis (G35)
  • Start/continuation dates
  • Clinical notes confirming MS subtype
  • Concurrent therapy information

3. Submit via Provider Portal

Who: Clinic staff
Timeline: Same day
Submit through Aetna's provider portal or fax to the number listed on the form. Include all supporting documentation.

4. Follow Up Within 5 Days

Who: Clinic staff
Timeline: Business days 3-5
Call Aetna to confirm receipt and check processing status. Request expedited review if clinically urgent.

5. Prepare for Potential Peer-to-Peer

Who: Prescribing physician
Timeline: Within 1 week of submission
Have patient charts, MRI reports, and treatment guidelines readily available for medical director review.

Medical Necessity Documentation

Clinician Corner: Your medical necessity letter is often the deciding factor in approval.

Essential Elements for Your Letter

MS Diagnosis Confirmation:

  • Specific MRI findings with dates
  • McDonald criteria fulfillment
  • MS phenotype classification (relapsing-remitting, secondary progressive with activity, primary progressive, or clinically isolated syndrome)

Prior Treatment History: Document all previous disease-modifying therapies including:

  • Medication names and duration of use
  • Specific reasons for discontinuation (lack of efficacy, side effects, contraindications)
  • Dates of treatment periods
  • Clinical outcomes or progression while on therapy

Current Clinical Rationale:

  • Recent EDSS score or functional assessment
  • Evidence of disease activity (new lesions, relapses, progression)
  • Why Ocrevus is appropriate for this patient's MS phenotype
  • Reference to current treatment guidelines

Safety Documentation:

  • Hepatitis B surface antigen and antibody results
  • Complete blood count within normal limits
  • Immunoglobulin levels if available

Template Structure

RE: Prior Authorization Request - Ocrevus (ocrelizumab)
Patient: [Name], DOB: [Date], Member ID: [Number]

DIAGNOSIS: Multiple Sclerosis (G35), confirmed by MRI on [date] showing [specific findings consistent with McDonald criteria]

CLINICAL HISTORY: Patient diagnosed with [MS type] in [year]. Disease course includes [relapses/progression details]. Current EDSS score: [if available].

PRIOR THERAPIES: Patient has trialed:
- [Drug name] from [date] to [date]: Discontinued due to [specific reason]
- [Drug name] from [date] to [date]: Discontinued due to [specific reason]

MEDICAL NECESSITY: Ocrevus is medically necessary as FDA-approved therapy for [patient's MS type]. Current MS treatment guidelines support anti-CD20 therapy for patients with [clinical scenario].

SAFETY SCREENING: Hepatitis B screening completed [date]: HBsAg negative, Anti-HBs [result].

Respectfully submitted,
[Physician name, credentials]
[NPI number]

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Medical necessity letter with guidelines AAN MS guidelines, FDA labeling
"Missing prior therapy documentation" Complete treatment history Medical records from all providers
"Inadequate diagnosis documentation" MRI reports and McDonald criteria Radiology reports, neurologist notes
"Safety screening incomplete" Submit all required labs Hepatitis B panel, CBC results
"Non-formulary medication" Request formulary exception Medical necessity justification

Appeals Process in Ohio

Internal Appeals with Aetna

Timeline: File within 60 days of denial
Decision time: 30 days (standard), 72 hours (expedited)
How to file: Submit written appeal with supporting documentation

Required elements:

  • Copy of original denial letter
  • Completed appeal form
  • Medical necessity letter from neurologist
  • Additional clinical evidence
  • Reference number from denial

Peer-to-Peer Review Strategy

Request immediately upon denial. Success rates improve significantly with peer-to-peer discussions.

Preparation checklist:

  • Have patient chart readily available
  • Review current MS treatment guidelines
  • Prepare specific examples of prior therapy failures
  • Document functional impairment or progression
From our advocates: We've seen peer-to-peer reviews succeed when physicians clearly articulate why standard alternatives failed and reference specific guideline recommendations. The conversation typically happens within 5-10 days and can overturn denials on the spot when clinical evidence is compelling.

Ohio External Review Process

If internal appeals fail, Ohio residents can request independent external review.

Key details:

  • Deadline: 180 days from final internal denial
  • Cost: Free to patients
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Contact: Ohio Department of Insurance at 800-686-1526

How to file:

  1. Complete external review request form
  2. Include all denial letters and medical documentation
  3. Submit to Aetna's appeals department as directed
  4. Ohio Department of Insurance assigns independent medical reviewers

Patient Assistance Programs

Genentech Access Solutions

Ocrevus CONNECTS: 844-627-3887

Available programs:

  • Copay assistance for commercially insured patients
  • Patient assistance program for uninsured/underinsured
  • Benefits investigation and prior authorization support

Enrollment: Complete the Ocrevus Start Form and submit via:

  • Fax: 877-312-2193
  • Online portal
  • Phone: 844-627-3887

CVS Specialty Pharmacy Enrollment

For patients whose Aetna plan uses CVS Specialty:

  1. Provider completes MS Infusion Enrollment Form
  2. Fax to 1-800-323-2445
  3. Patient calls CVS Specialty at 1-800-237-2767 to complete enrollment

When to Escalate

Contact Ohio Department of Insurance

When to call:

  • Aetna delays processing beyond standard timeframes
  • External review request is incorrectly denied
  • Questions about your appeal rights

Contact information:

File a Regulatory Complaint

If Aetna violates Ohio insurance regulations:

  • Improper denial without medical review
  • Failure to meet appeal deadlines
  • Incorrect application of policy terms

Submit complaints through the Ohio Department of Insurance complaint center.

Frequently Asked Questions

How long does Aetna prior authorization take for Ocrevus in Ohio?
Standard decisions typically take 30-45 days. Expedited reviews for urgent cases are completed within 72 hours.

What if Ocrevus isn't on Aetna's formulary?
Request a formulary exception with medical necessity documentation. Aetna must review non-formulary requests when medically necessary.

Can I request expedited appeal in Ohio?
Yes, if your physician certifies that delays could seriously jeopardize your health. Both Aetna and Ohio external review offer 72-hour expedited decisions.

Does step therapy apply if I tried other MS drugs outside Ohio?
Prior therapy documentation applies regardless of where treatment occurred. Gather records from all previous providers to demonstrate step therapy compliance.

What's the success rate for Ocrevus appeals?
While specific statistics vary, approximately 82% of Medicare Advantage appeals that proceed through multiple levels eventually succeed, indicating persistence improves outcomes.

How do I get help with my appeal in Ohio?
Contact the Ohio Department of Insurance at 800-686-1526 for guidance on appeals processes and external review procedures.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific denial basis, and creates targeted, evidence-backed rebuttals aligned to each plan's own rules. For medications like Ocrevus, we pull the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals that meet procedural requirements while tracking deadlines and required documentation.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always consult with your healthcare provider and insurance company for the most current requirements and procedures.

Sources & Further Reading

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