By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Aetna CVS Health in Washington: Appeals Guide with Forms and Timelines

Quick Answer: Getting Ocrevus Covered by Aetna CVS Health in Washington

Eligibility: Ocrevus requires prior authorization from Aetna CVS Health but has no step therapy requirement for FDA-approved MS indications. Your neurologist must confirm MS diagnosis using McDonald Criteria and document disease activity.

Fastest path to approval: Submit Aetna's Ocrevus precertification form with complete MS phenotype documentation, MRI reports, and hepatitis B screening. If denied, request peer-to-peer review immediately, then file internal appeal within 60 days. Washington residents can request external review within 180 days of final denial.

First step today: Contact your neurologist to gather all MS documentation and begin the Aetna Ocrevus precertification process.

Table of Contents

  1. Aetna's Coverage Policy for Ocrevus
  2. FDA Indication Requirements
  3. Step Therapy and Medical Exceptions
  4. Quantity and Frequency Limits
  5. Required Diagnostics and Documentation
  6. CVS Specialty Pharmacy Requirements
  7. Evidence to Support Medical Necessity
  8. Sample Medical Necessity Letter
  9. Appeals Process in Washington
  10. Common Denial Reasons and Solutions
  11. Costs and Patient Support
  12. FAQ

Aetna's Coverage Policy for Ocrevus

Aetna CVS Health covers Ocrevus (ocrelizumab) with prior authorization for all plan types—HMO, PPO, and Medicaid managed care. As of 2024, Ocrevus moved from the medical benefit to the pharmacy benefit, meaning it's now processed through CVS Specialty Pharmacy rather than as a medical infusion.

Plan Coverage Details:

  • Commercial plans: Prior authorization required, no step therapy
  • Medicaid (Apple Health): Covered with PA through Washington's managed care plans
  • Medicare Part D: Standard Medicare coverage rules apply

The official policy is outlined in Aetna's Multiple Sclerosis Clinical Policy Bulletin, which specifies coverage criteria for all MS disease-modifying therapies.

Note: Self-funded employer plans may have different requirements. Check your Summary Plan Description or contact member services to confirm your specific coverage.

FDA Indication Requirements

Ocrevus is FDA-approved for specific MS phenotypes, and Aetna's coverage aligns with these indications:

Covered Indications:

  • Relapsing forms of MS (including clinically isolated syndrome, relapsing-remitting MS, and active secondary progressive MS)
  • Primary progressive MS in adults

Documentation Required:

  • Confirmed MS diagnosis using McDonald Criteria (2017 revision)
  • MS phenotype classification by a neurologist
  • Evidence of active disease (recent relapses, new MRI lesions, or progression)

Off-Label Use: Aetna typically doesn't cover off-label uses without compelling medical necessity documentation and failure of FDA-approved alternatives.

Step Therapy and Medical Exceptions

Unlike many specialty medications, Ocrevus has no step therapy requirement under Aetna's standard policy for FDA-approved MS indications. This means you don't need to try and fail other disease-modifying therapies first.

Medical Exception Process: If your plan does require step therapy (some employer plans may vary), you can request a medical exception by:

  1. Submitting documentation that other DMTs are contraindicated
  2. Providing evidence of prior treatment failures or intolerance
  3. Including clinical rationale from your neurologist

Submit exceptions via:

  • Fax: 1-866-249-6155 (Specialty drugs)
  • Phone: 1-866-814-5506
  • Provider portal: Through Availity platform

Quantity and Frequency Limits

Aetna follows FDA-approved dosing for Ocrevus:

Dosing Limits:

  • Initial treatment: 300mg IV (first dose), then 300mg IV two weeks later
  • Maintenance: 600mg IV every 6 months
  • Ocrevus Zunovo (subcutaneous): 920mg every 6 months

Renewal Requirements:

  • Annual review of treatment response
  • Updated MRI showing disease stability or improvement
  • Neurologist assessment of continued benefit

Quantity Override: If you need dosing adjustments for medical reasons, your neurologist can request a quantity limit override with clinical justification.

Required Diagnostics and Documentation

Comprehensive documentation is crucial for Ocrevus approval. Gather these materials before submitting your prior authorization:

Essential Documentation:

Requirement Details Timing
MS Diagnosis McDonald Criteria confirmation, ICD-10 code G35 Within 12 months
MRI Reports Brain and spinal cord with gadolinium Within 6 months
Hepatitis B/C Screening HBsAg, anti-HBc, anti-HBs, HCV antibody Within 30 days
Complete Blood Count Including lymphocyte count Within 30 days
Immunoglobulin Levels Quantitative IgG, IgA, IgM Within 30 days
Vaccination History Live vaccines must be completed before treatment Current

Clinical Notes Must Include:

  • MS phenotype (RRMS, SPMS, PPMS)
  • EDSS score or functional assessment
  • Relapse history in past 12 months
  • Prior DMT history (if applicable)
  • Contraindications to other therapies

CVS Specialty Pharmacy Requirements

Since Ocrevus moved to the pharmacy benefit, it's now distributed through CVS Specialty Pharmacy for most Aetna plans.

Enrollment Process:

  1. Physician enrollment: Complete CVS Specialty enrollment forms
  2. Patient enrollment: Provide insurance information and delivery preferences
  3. Coordination: CVS coordinates infusion scheduling and administration

Infusion Services:

  • Home infusion: Available through CVS network nurses
  • Infusion centers: CVS-contracted facilities
  • Hospital outpatient: Must be CVS-contracted for coverage

Contact Information:

  • Enrollment: 1-866-899-1661
  • Fax: 1-866-843-3221
Tip: Verify that your preferred infusion site is in CVS's network before starting treatment to avoid unexpected costs.

Evidence to Support Medical Necessity

Strong clinical evidence strengthens your prior authorization request. Include these key elements:

Primary Evidence:

  • FDA prescribing information: Ocrevus prescribing information
  • Clinical trial data: OPERA I/II (RRMS) and ORATORIO (PPMS) studies
  • Practice guidelines: American Academy of Neurology MS guidelines

Supporting Documentation:

  • Recent peer-reviewed literature supporting Ocrevus use in your specific MS phenotype
  • Comparative effectiveness data vs. other DMTs
  • Safety profile relevant to your medical history

How to Cite: Keep citations concise but specific: "Per FDA label and OPERA trials, ocrelizumab significantly reduces relapse rates and MRI activity in RRMS patients."

Sample Medical Necessity Letter

Here's a template structure for your neurologist's medical necessity letter:

Patient: [Name, DOB, Member ID] Diagnosis: Multiple Sclerosis (ICD-10: G35), [specific phenotype]

Clinical Summary: "[Patient name] is a [age]-year-old with [MS phenotype] diagnosed in [year] meeting McDonald Criteria. Current EDSS score is [X.X]. Patient experienced [number] relapses in the past 12 months, with MRI dated [date] showing [findings]."

Medical Necessity: "Ocrelizumab is medically necessary for this patient based on: 1) FDA approval for [specific indication], 2) Evidence of active disease requiring highly effective DMT, 3) [Patient-specific factors such as prior treatment history, contraindications, etc.]"

Supporting Evidence: "Treatment is supported by FDA labeling, OPERA/ORATORIO clinical trials, and [relevant guidelines]. Expected outcomes include reduction in relapse rate and MRI activity."

Appeals Process in Washington

If your initial prior authorization is denied, Washington provides robust appeal rights:

Internal Appeals:

  1. First-level appeal: Submit within 60 days of denial
  2. Peer-to-peer review: Request physician-to-physician discussion
  3. Second-level appeal: If available under your plan

External Review (Washington-Specific): Washington residents have the right to independent external review:

  • Timeline: Request within 180 days of final internal denial
  • Process: Submit to Washington Office of Insurance Commissioner
  • Decision: Binding on Aetna, typically within 30 days
  • Cost: No charge to patient

Contact Information:

  • Washington OIC Consumer Advocacy: 1-800-562-6900
  • External Review Request: Follow instructions in denial letter

At this point, specialized platforms like Counterforce Health can be invaluable for patients and clinicians facing complex denials. Counterforce Health analyzes denial letters, identifies specific policy gaps, and drafts targeted appeals using evidence-based arguments that align with payer requirements—helping turn insurance denials into successful approvals.

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
"MS diagnosis not confirmed" Provide McDonald Criteria documentation Neurologist assessment, MRI reports, clinical notes
"Insufficient disease activity" Document recent relapses or MRI changes Relapse history, comparative MRIs, EDSS scores
"Missing lab work" Complete required screening Hepatitis B/C, CBC, immunoglobulins
"Not medically necessary" Strengthen clinical rationale Guidelines, peer-reviewed studies, patient-specific factors
"Experimental/investigational" Cite FDA approval and clinical evidence FDA label, clinical trials, practice guidelines

Scripts for Common Situations:

Peer-to-Peer Request Script: "I'm requesting a peer-to-peer review for [patient name], member ID [number]. The denial was based on [reason], but I have additional clinical information that supports medical necessity for Ocrevus."

Member Services Script: "I'm calling about a denied prior authorization for Ocrevus. My reference number is [number]. I'd like to understand the specific denial reason and start the appeal process."

Costs and Patient Support

Manufacturer Support:

  • Genentech Access Solutions: Copay assistance and patient support programs
  • Phone: 1-844-OCREVUS (1-844-627-3887)
  • Website: Ocrevus patient support

Financial Assistance:

  • Copay cards: May reduce out-of-pocket costs to $10 per infusion
  • Patient assistance programs: For uninsured or underinsured patients
  • Foundation grants: Multiple Sclerosis Association of America, National MS Society

Washington State Resources:

  • Washington Prescription Drug Program: Potential discounts for eligible residents
  • Apple Health: Medicaid expansion covers Ocrevus with prior authorization

FAQ

How long does Aetna CVS Health prior authorization take for Ocrevus? Standard decisions are made within 15 business days. Expedited reviews (for urgent situations) are processed within 24-72 hours.

What if Ocrevus is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Success rates are higher when you demonstrate that formulary alternatives are inappropriate or ineffective.

Can I request an expedited appeal in Washington? Yes, if delay could seriously jeopardize your health, you can request expedited review. Decisions are typically made within 72 hours.

Does step therapy apply if I've failed treatments outside Washington? Yes, prior treatment history from other states counts toward step therapy requirements, provided you have proper documentation of trials and outcomes.

What happens if CVS Specialty isn't available in my area? Aetna may provide exceptions for out-of-network specialty pharmacies if CVS services aren't accessible. Contact member services to discuss options.

How do I file a complaint with Washington insurance regulators? Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 or file online at their consumer complaint portal.

For patients navigating complex Ocrevus denials, Counterforce Health offers specialized support by analyzing payer policies, identifying denial weaknesses, and crafting evidence-based appeals that speak directly to insurance companies' coverage criteria—significantly improving approval chances for specialty medications like Ocrevus.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage questions. For additional help with insurance appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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