By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Cigna in Georgia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Ocrevus (Ocrelizumab) Covered by Cigna in Georgia

Cigna requires prior authorization for Ocrevus (ocrelizumab) with documented MS diagnosis, hepatitis B screening (negative), and typically trial/failure of first-line DMTs for relapsing forms. Submit PA via neurologist through Cigna provider portal or specialty pharmacy forms. If denied, file internal appeal within 180 days, then Georgia external review within 60 days. First step today: Verify your plan's formulary status and gather hepatitis B labs, prior DMT records, and recent MRI/EDSS documentation.

Table of Contents

  1. Coverage at a Glance
  2. Policy Overview: How Cigna Covers Ocrevus in Georgia
  3. Medical Necessity Requirements
  4. Step Therapy and Exceptions
  5. Required Diagnostics and Documentation
  6. Specialty Pharmacy Requirements
  7. Fastest Path to Approval
  8. Appeals Process for Georgia Residents
  9. Common Denial Reasons and Solutions
  10. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Mandatory for all Ocrevus prescriptions Cigna provider portal or PA forms Cigna Policy
Formulary Tier Specialty tier (high copay) myCigna app/portal Plan Documents
Step Therapy Trial/failure of ≥1 DMT for relapsing MS Clinical documentation required Coverage Policy
Specialty Pharmacy Must fill through Accredo/Express Scripts Prescription routing Specialty Pharmacy Guide
Age Requirement ≥18 years Patient demographics FDA Label
Appeals Deadline 180 days (internal), 60 days (external) Denial notice Georgia DOI

Policy Overview: How Cigna Covers Ocrevus in Georgia

Cigna covers Ocrevus (ocrelizumab) and Ocrevus Zunovo (subcutaneous formulation) as specialty-tier medications across their Georgia plans, including HMO, PPO, and Medicare Advantage products. Coverage requires prior authorization regardless of plan type, with specific criteria outlined in Cigna's coverage policy IP_0212.

Plan Types in Georgia:

  • Commercial Plans: Standard PA requirements apply
  • Medicare Advantage: Additional CMS guidelines may apply
  • Medicaid (limited expansion): Check Georgia Medicaid formulary separately

All Cigna plans route Ocrevus through their specialty pharmacy partner, Express Scripts/Accredo, which handles both dispensing and prior authorization coordination.

Medical Necessity Requirements

Cigna considers Ocrevus medically necessary for adults (≥18 years) with confirmed multiple sclerosis meeting these criteria:

For Relapsing MS (RRMS, CIS, Active SPMS)

  • Confirmed diagnosis using McDonald Criteria
  • Disease activity documented by:
    • ≥1 clinical relapse in past 12 months, OR
    • MRI evidence (gadolinium-enhancing T1 or new/enlarging T2 lesions)
  • Functional status: Able to ambulate without aid/rest for ≥100 meters
  • Monotherapy use: No concurrent DMTs

For Primary Progressive MS (PPMS)

  • Confirmed PPMS diagnosis independent of relapses
  • EDSS score ≤6.5
  • Ambulation >5 meters without aid
  • Documented progression in prior 12 months
Clinician Corner: Medical necessity letters should reference the American Academy of Neurology guidelines and include specific EDSS scores, MRI dates/findings, and functional assessments. Cigna reviewers look for objective evidence of disease activity and disability progression.

Step Therapy and Exceptions

Most Cigna plans require documented trial and failure (or contraindication) of at least one first-line DMT before approving Ocrevus for relapsing MS:

Required First-Line Trials:

  • Injectable interferons (Avonex, Rebif, Betaseron, Plegridy)
  • Glatiramer acetate (Copaxone, Glatopa)
  • Oral DMTs (Tecfidera, Gilenya, Aubagio, Mayzent)

Exception Pathways:

  • Medical contraindication: Document specific reasons (e.g., injection site reactions, liver enzyme elevation)
  • Treatment failure: Breakthrough relapses or MRI progression despite adequate trial (typically 6+ months)
  • Intolerance: Documented adverse effects preventing continuation

PPMS Exception: Step therapy typically doesn't apply to PPMS since most first-line DMTs aren't FDA-approved for this indication.

Counterforce Health specializes in helping patients navigate these step therapy requirements by identifying the strongest clinical evidence to support exceptions when appropriate.

Required Diagnostics and Documentation

Mandatory Lab Work

Hepatitis B Screening (absolute requirement):

  • HBsAg (hepatitis B surface antigen)
  • Anti-HBc (hepatitis B core antibody)
  • Results must be negative for active infection

Additional Labs:

  • Complete blood count (baseline)
  • Liver function tests
  • Immunoglobulin levels (if history of recurrent infections)

Clinical Documentation

  • Recent MRI (within 6 months): T1 with gadolinium, T2-FLAIR sequences
  • EDSS assessment by neurologist
  • Prior DMT records: Medications tried, duration, reason for discontinuation
  • Vaccination status: Complete immunizations ≥6 weeks before starting
Note: Ocrevus prescribing information requires hepatitis B screening due to risk of viral reactivation with B-cell depletion.

Specialty Pharmacy Requirements

Cigna mandates that all Ocrevus prescriptions be filled through their specialty pharmacy network:

Primary Specialty Pharmacy: Accredo

  • Phone: 1-800-803-2523 (verify with current plan documents)
  • Handles both IV (Ocrevus) and subcutaneous (Ocrevus Zunovo) formulations

Prescription Routing:

  1. Neurologist submits PA and prescription simultaneously
  2. Accredo coordinates with infusion center for IV formulation
  3. Patient receives medication at approved infusion site

Site of Care: Ocrevus IV must be administered in healthcare facility; subcutaneous Ocrevus Zunovo allows home administration after training.

Fastest Path to Approval

Step 1: Verify Coverage (Patient/Family - Day 1)

  • Log into myCigna portal to check formulary status
  • Confirm specialty pharmacy requirements
  • Note your plan's specific PA form requirements

Step 2: Gather Documentation (Clinic Staff - Days 1-3)

  • Obtain hepatitis B screening results
  • Compile prior DMT trial records
  • Schedule recent MRI if >6 months old
  • Document current EDSS score

Step 3: Submit Prior Authorization (Neurologist - Day 3-5)

  • Complete Cigna PA form or submit via provider portal
  • Include medical necessity letter citing specific criteria
  • Submit prescription to Accredo simultaneously

Step 4: Follow Up (Clinic Staff - Day 7-10)

  • Standard PA decision: ≤14 days
  • Expedited (urgent cases): 72 hours
  • Track status via Cigna provider portal

Step 5: If Approved (Patient/Clinic - Day 14-21)

  • Accredo contacts patient for enrollment
  • Schedule infusion appointment
  • Complete pre-infusion requirements

Appeals Process for Georgia Residents

If Cigna denies your Ocrevus prior authorization, Georgia residents have specific appeal rights under state insurance law:

Internal Appeals (Required First Step)

Level 1 Internal Appeal:

  • Deadline: 180 days from denial notice
  • Decision time: 30 days (72 hours if expedited)
  • How to file: Written appeal via Cigna customer service or provider portal

Level 2 Internal Appeal:

  • Deadline: 60 days from Level 1 denial
  • Decision time: 30 days (72 hours if expedited)
  • Final internal decision required before external review

External Review (Georgia Department of Insurance)

After exhausting Cigna's internal appeals, Georgia residents can request external review for medical necessity denials:

  • Deadline: 60 days from final internal denial
  • Decision time: 30 business days (72 hours if expedited)
  • How to file: Georgia DOI website or Consumer Services: 1-800-656-2298
  • Cost: Free to consumer
  • Decision: Binding on Cigna if approved
Tip: Georgia allows concurrent expedited external review if your medical situation is urgent—you don't have to wait for internal appeals to complete if delay poses serious health risk.

When appealing Ocrevus denials, Counterforce Health helps patients and clinicians build evidence-based appeals that address the specific denial reasons with targeted clinical documentation and payer-specific arguments.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Step therapy not met Document failed/contraindicated first-line DMTs Prior therapy records, adverse event notes, progression despite treatment
Insufficient disease activity Provide recent MRI and relapse history Gadolinium-enhancing lesions, new T2 lesions, documented relapses
Missing hepatitis B screening Submit required lab results HBsAg and anti-HBc results (must be negative)
Not medically necessary Strengthen clinical rationale Neurologist letter citing AAN guidelines, functional assessments
Combination therapy concern Confirm monotherapy use Medication reconciliation, washout documentation

FAQ

How long does Cigna prior authorization take for Ocrevus in Georgia? Standard PA decisions take up to 14 days; expedited requests (for urgent medical situations) are decided within 72 hours. Specialty drugs may take the full timeframe due to clinical review requirements.

What if Ocrevus is non-formulary on my Cigna plan? Request a formulary exception with medical necessity documentation. Your neurologist must demonstrate that formulary alternatives are inappropriate for your specific MS type.

Can I request an expedited appeal in Georgia? Yes, if delay in treatment poses serious risk to your health. Both Cigna internal appeals and Georgia external review offer expedited pathways with 72-hour decision timelines.

Does step therapy apply if I failed DMTs in another state? Yes, prior therapy trials from any state count toward step therapy requirements. Ensure your Georgia neurologist has complete records from your previous providers.

What's the success rate for Ocrevus appeals in Georgia? Specific success rates aren't publicly available, but Georgia's external review process provides independent medical review that has overturned many wrongful denials for specialty medications when proper clinical evidence is submitted.

Who pays for Ocrevus if my appeal is successful? If your appeal is approved, Cigna must cover the medication according to your plan's benefit structure (you'll pay your normal specialty tier copay/coinsurance).

From Our Advocates: "We've seen many Ocrevus denials overturned when families gather comprehensive documentation upfront—especially hepatitis B screening, detailed prior therapy records, and recent MRI reports. The key is addressing Cigna's specific criteria point-by-point rather than submitting generic medical necessity letters. While outcomes vary by individual case, thorough preparation significantly improves approval chances."

Disclaimer: This guide provides educational information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance professional. Coverage policies and state regulations may change; always verify current requirements with official sources.

Need Help With Your Appeal? Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, pulling the right clinical evidence and operational details that reviewers expect.

Sources & Further Reading

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