By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Blue Cross Blue Shield North Carolina: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Ocrevus Covered in North Carolina

To get Ocrevus (ocrelizumab) covered by Blue Cross Blue Shield North Carolina, you'll need prior authorization through their specialty pharmacy network. Start today by having your neurologist submit a PA request via CoverMyMeds.com with your MS diagnosis, prior therapy failures, and clinical justification. If denied, you have 65 days to appeal internally, then 120 days for North Carolina's free Smart NC external review (855-408-1212). Most approvals happen within 3 business days when complete documentation is submitted.

Table of Contents

  1. Verify Your Plan and Coverage
  2. Prior Authorization Forms and Requirements
  3. Online Submission Portals
  4. Fax and Mail Options
  5. Specialty Pharmacy Network
  6. Support Phone Numbers
  7. North Carolina External Review Process
  8. Appeals Playbook
  9. Common Denial Reasons and Solutions
  10. Patient Support and Cost Assistance

Verify Your Plan and Coverage

Before starting your Ocrevus prior authorization, confirm your specific Blue Cross Blue Shield North Carolina plan details. Use the Blue Cross NC prescription drug search tool to check if Ocrevus requires prior authorization on your formulary.

Key details to gather:

  • Your member ID number and group number
  • Plan type (HMO, PPO, or marketplace)
  • Current formulary tier for Ocrevus
  • Any step therapy requirements
Note: Blue Cross Blue Shield of North Carolina operates independently from other Blue Cross plans, so coverage policies may differ from other states.

Prior Authorization Forms and Requirements

Coverage Criteria for Ocrevus

Blue Cross NC typically requires prior authorization for Ocrevus with these medical necessity criteria:

For Relapsing Forms of MS:

  • Confirmed diagnosis of clinically isolated syndrome (CIS), relapsing-remitting MS, or active secondary progressive MS
  • Documentation of disease activity (relapses or MRI lesions)
  • Age 18 or older

For Primary Progressive MS:

  • Confirmed PPMS diagnosis
  • Evidence of disease progression
  • Elevated disability scores when clinically appropriate

Required Documentation

Your neurologist must submit:

  1. Clinical notes documenting MS phenotype and disability progression
  2. MRI reports showing characteristic lesions or new activity
  3. Prior therapy documentation if step therapy applies to your plan
  4. Laboratory results including hepatitis B screening
  5. Vaccination status (live vaccines must be completed before starting)

Online Submission Portals

Primary Electronic Submission

CoverMyMeds is Blue Cross NC's preferred electronic prior authorization platform:

  • Website: CoverMyMeds.com
  • Processing time: 3 business days for complete submissions
  • Status tracking available for providers and patients

Alternative Portals

For Healthy Blue (Medicaid) members:

  • Availity.com - Select Patient Registration > Authorizations > General Pharmacy
  • Phone support: 844-594-5072

MHK Provider Portal (accessed via Blue e) provides additional submission options for contracted providers.

Fax and Mail Options

If online submission isn't available, use these backup methods:

Fax: 800-795-9403 Processing time: 3 business days after receipt

Mail submissions (verify current address with Blue Cross NC): Blue Cross and Blue Shield of North Carolina Prior Authorization Department [Contact customer service at 888-274-5186 for current mailing address]

Tip: Include a cover sheet with member ID, drug name, and prescriber contact information for faster processing.

Specialty Pharmacy Network

Ocrevus must be obtained through Blue Cross NC's specialty pharmacy network. The primary options include:

BioPlus Specialty Pharmacy:

  • Phone: 833-549-2115 (TTY 711)
  • Available 24/7
  • Free shipping and confidential delivery
  • Online prescription management

Accredo Specialty Pharmacy:

  • Phone: 833-599-0513
  • Coordination with infusion centers
  • Patient support services

Infusion Site Requirements

For IV Ocrevus, confirm your infusion center is in-network. Blue Cross NC may require specific sites of care for specialty infusions to manage costs and ensure proper administration.

Support Phone Numbers

Blue Cross NC Customer Service: 888-274-5186

  • General coverage questions
  • Prior authorization status
  • Appeals assistance

Specialty Pharmacy Support:

  • BioPlus: 833-549-2115
  • Accredo: 833-599-0513

Provider Prior Authorization Line:

  • CarelonRx: 833-293-0659
  • Healthy Blue: 844-594-5072 (24-hour turnaround)

North Carolina External Review Process

If Blue Cross NC denies your Ocrevus coverage after internal appeals, North Carolina's Smart NC program provides free, independent review.

How Smart NC Works

Contact Information:

Timeline:

  • Standard review: 45 days for decision
  • Expedited review: 72 hours for urgent cases
  • Ultra-expedited: 24 hours for life-threatening situations

Success Factors: Smart NC's independent review organizations aren't bound by Blue Cross NC's internal policies. They review based on medical necessity and established treatment guidelines.

From our advocates: We've seen Smart NC overturn specialty drug denials when patients provided comprehensive clinical documentation showing failed prior therapies and clear medical necessity. The key is submitting complete records that demonstrate why Ocrevus is the most appropriate treatment option.

Filing an External Review

You have 120 days from your final internal denial to request external review. Smart NC staff can help you complete the application and gather supporting documentation.

Required information:

  • Final denial letter from Blue Cross NC
  • Medical records supporting medical necessity
  • Physician statement explaining why Ocrevus is necessary

Appeals Playbook

Internal Appeals Process

Level 1 Appeal:

  • Deadline: 65 days from denial notice
  • Method: Email [email protected] or use member portal
  • Timeline: 7 calendar days for standard review
  • Expedited: 72 hours if urgent medical need

Required Information:

  • Full name and member ID
  • Drug name (Ocrevus/ocrelizumab)
  • Prescriber information
  • Reason you believe coverage should be approved

What to Include in Your Appeal

  1. Updated clinical notes showing disease progression or inadequate response to other treatments
  2. Peer-reviewed literature supporting Ocrevus for your MS type
  3. Patient impact statement describing how denial affects your health and quality of life
  4. Physician letter explaining medical necessity and treatment rationale

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-based rebuttals. Their platform helps patients and providers navigate complex prior authorization requirements and appeal processes. Learn more about their services.

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
No confirmed MS diagnosis Submit MRI reports and neurologist consultation notes McDonald criteria documentation, lesion characteristics
Step therapy not completed Document failed/contraindicated prior DMTs Pharmacy records, adverse event reports, medical contraindications
Missing safety screening Complete required labs and vaccinations Hepatitis B panel, vaccination records, CBC with differential
Combination therapy concern Justify concurrent treatments or discontinue conflicting medications Clinical rationale for combination, drug interaction assessment
Not medically necessary Provide evidence of disease activity and treatment goals Recent MRI showing activity, EDSS scores, relapse documentation

Patient Support and Cost Assistance

Manufacturer Support Programs

Genentech Patient Foundation:

  • Copay assistance for eligible patients
  • Financial hardship programs
  • Patient access services

MS Society Resources:

  • Equipment loan programs
  • Financial assistance
  • Local chapter support

State-Specific Resources

North Carolina Medicaid: With expansion effective 2024, more patients may qualify for Medicaid coverage of specialty medications.

Health Insurance Marketplace: Premium tax credits and cost-sharing reductions may be available through HealthCare.gov.

Clinician Corner: Medical Necessity Documentation

When submitting prior authorization or appeals, include these key clinical elements:

Problem Statement:

  • Specific MS phenotype (RRMS, CIS, active SPMS, or PPMS)
  • Current disability level and functional impact
  • Disease activity markers (relapses, MRI progression)

Prior Treatment History:

  • Previous DMTs tried, duration, and outcomes
  • Reasons for discontinuation (lack of efficacy, adverse events, contraindications)
  • Current symptom management approaches

Clinical Rationale:

  • Why Ocrevus is most appropriate for this patient
  • Expected treatment outcomes and monitoring plan
  • Dosing rationale (standard 600mg every 6 months)

Supporting Evidence:

  • FDA labeling for approved indications
  • MS society treatment guidelines
  • Relevant peer-reviewed studies

FAQ

How long does Blue Cross Blue Shield NC prior authorization take? Standard processing is 3 business days for complete submissions via CoverMyMeds. Expedited reviews for urgent cases are completed within 24 hours.

What if Ocrevus isn't on my formulary? You can request a formulary exception by having your doctor explain why preferred alternatives aren't appropriate. Include clinical documentation supporting medical necessity.

Can I get an expedited appeal if my MS is worsening? Yes, if your physician attests that delay would jeopardize your health, Blue Cross NC must process expedited appeals within 72 hours.

Does step therapy apply if I've tried other DMTs in another state? Yes, provide pharmacy records and clinical notes from your previous treatments, even if received outside North Carolina.

What happens if my internal appeal is denied? You have 120 days to file for external review through Smart NC, which provides independent review at no cost to you.

Staying Updated on Requirements

Blue Cross NC policies and forms can change annually or with plan updates. Check these resources regularly:

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by individual plan. Always consult with your healthcare provider and insurance plan directly for the most current requirements and procedures specific to your situation.

For additional support navigating insurance coverage challenges, Counterforce Health provides specialized assistance with prior authorization appeals and evidence-based coverage strategies.

Sources & Further Reading

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