By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Blue Cross Blue Shield of Michigan: 2024 Prior Authorization Guide

Answer Box: Getting Ocrevus Covered by Blue Cross Blue Shield Michigan

Blue Cross Blue Shield of Michigan requires prior authorization for Ocrevus (ocrelizumab). Submit requests through the NovoLogix tool via Availity. If denied, you have 60 days for internal appeals and 127 days for external review through Michigan DIFS. First step today: Have your neurologist gather documentation of MS diagnosis, prior DMT failures, and vaccination records, then submit the PA request online.

Table of Contents

  1. Why Michigan State Rules Matter for Ocrevus Coverage
  2. Prior Authorization Requirements and Turnaround Times
  3. Step Therapy Protections and Medical Exceptions
  4. Continuity of Care During Coverage Transitions
  5. External Review and Appeals Process
  6. Practical Scripts and Communication Tools
  7. Coverage Limitations and ERISA Plans
  8. Quick Reference Contacts and Forms
  9. FAQ: Common Ocrevus Coverage Questions

Why Michigan State Rules Matter for Ocrevus Coverage

Michigan's insurance landscape is dominated by Blue Cross Blue Shield of Michigan, which covers approximately 67% of commercial plan members. The state's Patient's Right to Independent Review Act provides stronger consumer protections than federal minimums, giving you 127 days (rather than the standard 120) to file external appeals.

For Ocrevus, this matters because multiple sclerosis treatments often face complex prior authorization requirements. Michigan law ensures that step therapy protocols cannot force you to repeat medications that have already proven ineffective or unsafe—a crucial protection for MS patients who may have tried multiple disease-modifying therapies.

Note: Self-funded employer plans (ERISA) may not be subject to all Michigan state protections, though they still follow federal appeal rights.

Prior Authorization Requirements and Turnaround Times

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for Ocrevus Zunovo SC NovoLogix via Availity BCBSM Alert
Approved Sites Office, ambulatory center, home infusion Site-of-care restrictions apply BCBSM Provider Info
Standard Review 5-7 business days For non-urgent requests Sprypt PA Guide
Urgent Review 24-48 hours With physician urgency statement Sprypt PA Guide

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Confirmed MS diagnosis with phenotype (RRMS, SPMS, PPMS)
    • Previous DMT trials and outcomes
    • Current vaccination status and HBV screening results
    • Timeline: 1-2 days to compile
  2. Submit PA Request Online (Provider)
  3. Await Initial Determination (BCBSM)
    • Automatic approval if criteria met
    • Timeline: 5-7 business days standard, 24-48 hours urgent
  4. If Denied, Request Internal Appeal (Patient/Provider)
    • Submit within 60 days of denial
    • Timeline: Decision within 60 calendar days
  5. External Review if Needed (Michigan DIFS)
    • File within 127 days of final internal denial
    • Timeline: Standard 60 days, expedited 72 hours

Step Therapy Protections and Medical Exceptions

Michigan law provides specific protections against inappropriate step therapy requirements. For Ocrevus, BCBSM may require you to try preferred DMTs first, but exceptions are available when:

  • Previous DMT caused adverse reactions
  • Contraindications exist to preferred alternatives
  • You've already failed preferred therapies (even with other insurers)
  • Clinical factors make alternatives inappropriate

Medical Exception Documentation

Your neurologist should include:

  • Specific prior DMT names and dates tried
  • Detailed reason for discontinuation (efficacy failure, side effects, contraindications)
  • Clinical rationale for Ocrevus based on MS phenotype and disease activity
  • Supporting literature from MS treatment guidelines
Tip: Michigan regulations specify that patients shouldn't be forced to repeat failed therapies when changing plans. Document all previous treatments thoroughly.

Continuity of Care During Coverage Transitions

If you're already stable on Ocrevus and switch to BCBSM, you may qualify for a continuity of care period. This typically provides at least 60 days of continued coverage while your new prior authorization is processed.

To request continuity coverage:

  1. Contact BCBSM member services immediately upon enrollment
  2. Provide documentation of current Ocrevus therapy
  3. Request temporary coverage pending PA review
  4. Have your neurologist submit the PA request promptly

Counterforce Health specializes in helping patients navigate these transitions by automatically generating appeals that address payer-specific requirements and include the right clinical evidence to support continuity requests.

External Review and Appeals Process

Internal Appeals with BCBSM

Standard Internal Appeal:

  • Deadline: 60 days from denial notice
  • Submission: Use BCBSM Member Appeal Form
  • Timeline: Decision within 60 calendar days
  • Required: Copy of denial, medical records, provider statement

Urgent Internal Appeal:

  • When to use: Delay would seriously jeopardize health
  • Timeline: Decision within 72 hours
  • Required: Physician statement of urgency

External Review Through Michigan DIFS

If BCBSM upholds the denial, you can request an independent external review:

Contact Information:

Requirements:

  • Must file within 127 days of final BCBSM denial
  • Include copy of denial letter and supporting documentation
  • External review by independent medical experts
  • Decision is binding on BCBSM

Practical Scripts and Communication Tools

Patient Phone Script for BCBSM

"Hello, I'm calling about a prior authorization denial for Ocrevus. My member ID is [number]. I'd like to request an internal appeal and understand the specific reason for denial. Can you please transfer me to the appeals department and provide the exact clinical criteria that wasn't met?"

Clinic Staff Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for [patient name]'s Ocrevus denial. The patient has [specific MS phenotype], has failed [list DMTs with dates], and meets medical necessity criteria per the 2024 MS treatment guidelines. When can we schedule the physician-to-physician discussion?"

Email Template for Documentation Requests

"Subject: Urgent - Ocrevus PA Documentation Needed

Dear [Provider Name],

BCBSM has denied coverage for Ocrevus. For our appeal, please provide:

  • MS diagnosis confirmation with phenotype
  • Previous DMT trial history with specific outcomes
  • Current MRI reports showing disease activity
  • Statement of medical necessity

Appeal deadline: [date]. Please send by [deadline minus 5 days].

Thank you."

Coverage Limitations and ERISA Plans

Self-Funded Employer Plans

Many large employers in Michigan offer self-funded plans that use BCBSM as an administrator but aren't subject to all state insurance laws. These ERISA plans:

  • May have different appeal timelines (federal standards)
  • Might not offer the 127-day external review window
  • Still must provide internal appeals and federal external review rights

How to identify: Look for "Administrative Services Only" or "ASO" on your insurance card or benefits summary.

What This Means for Ocrevus

ERISA plans may have:

  • Stricter step therapy requirements
  • Different prior authorization criteria
  • Limited state-level appeal protections

However, federal law still requires fair appeals processes and external review options.

Quick Reference Contacts and Forms

BCBSM Resources

Michigan DIFS

Key Deadlines

  • Internal Appeal: 60 days from denial
  • External Review: 127 days from final internal denial
  • Urgent Reviews: 72 hours for decisions

FAQ: Common Ocrevus Coverage Questions

Q: How long does BCBSM prior authorization take for Ocrevus? A: Standard requests take 5-7 business days, while urgent requests are processed within 24-48 hours if your physician provides an urgency statement.

Q: What if Ocrevus isn't on BCBSM's formulary? A: You can request a formulary exception by having your neurologist submit clinical justification for why preferred alternatives aren't appropriate for your case.

Q: Can I request an expedited appeal in Michigan? A: Yes, both BCBSM internal appeals and DIFS external reviews offer expedited processing (72 hours) when delays would seriously jeopardize your health.

Q: Does step therapy apply if I failed DMTs with a previous insurer? A: Michigan law protects against repeating failed therapies. Document all previous treatments and outcomes when submitting your PA request.

Q: What vaccination requirements exist for Ocrevus coverage? A: BCBSM typically requires up-to-date vaccinations before starting Ocrevus due to infection risks. Your neurologist should document vaccination status in the PA request.

Q: How does site-of-care affect Ocrevus coverage? A: BCBSM approves administration in physician offices, ambulatory infusion centers, and home infusion settings. Hospital outpatient settings may require additional documentation.

Q: What happens if I need Ocrevus while my appeal is pending? A: You may be able to get temporary coverage through BCBSM's continuity of care provisions or by requesting an urgent review if delays would harm your health.

From Our Advocates: We've seen many Michigan patients successfully overturn Ocrevus denials by thoroughly documenting previous DMT failures and including specific MRI evidence of disease activity. The key is often providing detailed timelines of prior treatments rather than just listing medication names. This composite guidance reflects common successful strategies, though individual outcomes vary.

For complex cases involving multiple denials or urgent medical needs, Counterforce Health helps patients and providers create evidence-backed appeals that address specific payer requirements and include the clinical documentation most likely to result in approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your insurer and consult healthcare providers for medical decisions. For the most current forms and contact information, visit official BCBSM and Michigan DIFS websites.

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