By Counterforce Health Team in Ocrevus (ocrelizumab) —

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

Answer Box: Getting Ocrevus Covered by Cigna in Michigan

Cigna requires prior authorization for Ocrevus (ocrelizumab) in Michigan. Your neurologist must submit clinical documentation showing MS diagnosis, prior DMT failure/intolerance, and recent disease activity. Standard approval takes 5 business days; if denied, you have 180 days for internal appeals, then 127 days for external review through Michigan DIFS. Start today: Have your neurologist download Cigna's Ocrevus CCRD form and gather your MRI results, relapse history, and prior therapy records.

Table of Contents

Plan Types & Network Requirements

Understanding your specific Cigna plan type affects how you access neurologists and specialty treatments in Michigan:

HMO and Network Plans: Require a primary care provider (PCP) referral to see an in-network neurologist. Your PCP must issue a written referral, submit it to Cigna if required, and the referral remains valid for up to 6 months per treatment plan.

PPO Plans: No PCP referral needed. You can see any in-network or out-of-network neurologist, though out-of-network care typically costs more.

EPO Plans: No referrals required, but coverage is limited to in-network providers only (except for emergencies).

Tip: Log into myCigna or use the provider portal at CignaforHCP.com to verify your plan's referral requirements and find in-network neurologists in Michigan.

Formulary Status & Coverage Rules

Ocrevus appears on most Cigna formularies but typically requires prior authorization regardless of tier placement. The medication is managed through Express Scripts/Accredo for specialty pharmacy services.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all plans Cigna PA Forms
Specialty Pharmacy Must use Accredo (preferred) Accredo Enrollment
Step Therapy Plan-dependent; check formulary Current PDL on cigna.com
Site of Care Home, office, or clinic infusion PA form specifies options

Prior Authorization Process

Cigna's prior authorization for Ocrevus requires comprehensive clinical documentation submitted via their official CCRD form.

Required Clinical Documentation

  • MS Diagnosis: Confirmed relapsing or primary progressive multiple sclerosis
  • Prior DMT History: Trial/failure or intolerance of at least one disease-modifying therapy
  • Disease Activity: Recent relapses, MRI changes, or disability progression
  • Laboratory Results: Hepatitis B screening required
  • PPMS-Specific: EDSS score ≤6.5, ability to ambulate >5 meters, progression within prior year

Submission Methods

  • Online: CoverMyMeds (preferred)
  • EHR: SureScripts integration
  • Fax: 855-840-1678
  • Phone: 800-882-4462 (urgent requests)

Timelines

  • Standard PA: 5 business days
  • Urgent PA: 72 hours (requires physician attestation of serious jeopardy)
  • Michigan Law: If Cigna doesn't respond within 15 days (standard) or 72 hours (urgent), the request is automatically approved

Specialty Pharmacy Enrollment

Cigna directs Ocrevus prescriptions to Accredo, their preferred specialty pharmacy partner.

Enrollment Steps

  1. Prescriber completes Accredo Ocrevus form
  2. Patient information: Name, DOB, insurance cards (front/back), contact preferences
  3. Clinical details: Primary ICD-10 code (G35 for MS), infusion site preference
  4. Submission: Fax to 888.302.1028 or e-prescribe to NCPDP 4436920
Note: Patients can call Accredo at 844.516.3319 for enrollment support and create an online account at MyAccredoPatients.com after the first prescription is processed.

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient + Clinic)
    • Recent MRI reports showing MS lesions
    • Complete list of prior DMTs tried and outcomes
    • Hepatitis B screening results
    • Current EDSS score (if available)
  2. Neurologist Downloads Forms
  3. Submit Prior Authorization (Neurologist)
    • Complete all clinical sections thoroughly
    • Submit via CoverMyMeds or fax to 855-840-1678
    • Timeline: 5 business days standard
  4. Enroll with Accredo (Parallel Process)
    • Neurologist submits prescription form
    • Patient calls 844.516.3319 for setup
    • Timeline: 2-3 business days
  5. Monitor Status
    • Check PA status via Cigna provider portal
    • Follow up if no response within 10 days
  6. Schedule Infusion (Upon Approval)
    • Coordinate with infusion center
    • Confirm insurance authorization
    • Schedule pre-medications if needed
  7. Appeal if Denied (See Appeals Section)
    • Internal appeal within 180 days
    • External review through Michigan DIFS

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"No confirmed MS diagnosis" Provide MRI reports and neurologist notes Recent brain/spine MRI, clinical notes
"Insufficient prior therapy" Document DMT trials and outcomes Therapy records, failure/intolerance notes
"Not medically necessary" Submit medical necessity letter Neurologist letter citing guidelines
"Missing lab work" Provide hepatitis B screening Recent HBsAg, anti-HBc results
"Combination therapy" Clarify monotherapy use Updated prescription, discontinuation notes

Medical Necessity Letter Checklist

Your neurologist's appeal letter should include:

  • Specific MS phenotype (relapsing vs. PPMS)
  • Prior DMT history with dates and outcomes
  • Recent disease activity evidence
  • Reference to FDA labeling and MS treatment guidelines
  • Monitoring plan and expected outcomes

Appeals Process in Michigan

Michigan offers robust appeal rights under the Patient's Right to Independent Review Act, administered by the Department of Insurance and Financial Services (DIFS).

Internal Appeals (Cigna)

  • Timeline: File within 180 days of denial
  • Decision: 30 days for pre-service appeals
  • Submission: Call customer service number on ID card or use appeal form
  • Include: Denial letter, medical records, neurologist support letter

External Review (Michigan DIFS)

  • Timeline: File within 127 days of final internal denial
  • Decision: 60 days standard, 72 hours expedited
  • Cost: Free to patients
  • Submission: Online form or call 877-999-6442
  • Authority: Binding decision on Cigna
Important: For expedited external review, your physician must certify that waiting would seriously jeopardize your health.

When traditional appeals processes feel overwhelming, platforms like Counterforce Health can help patients and clinicians turn insurance denials into targeted, evidence-backed appeals. Their system ingests denial letters and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to the plan's own rules.

Costs & Patient Assistance

Insurance Coverage

  • Deductible: May apply before coverage begins
  • Coinsurance: Typically 10-40% for specialty medications
  • Out-of-pocket maximum: Annual limit varies by plan

Patient Assistance Programs

  • Genentech Copay Card: May reduce out-of-pocket costs (verify eligibility)
  • Genentech Patient Foundation: Need-based assistance program
  • State Programs: Michigan may offer additional support through Medicaid or other programs
Note: Copay assistance programs typically cannot be combined with government insurance (Medicare, Medicaid).

FAQ

How long does Cigna prior authorization take in Michigan? Standard PA decisions are made within 5 business days. Michigan law requires automatic approval if Cigna doesn't respond within 15 days for standard requests or 72 hours for urgent requests.

What if Ocrevus is non-formulary on my plan? Your neurologist can request a formulary exception by documenting medical necessity and why preferred alternatives aren't suitable. Submit through the same PA process with additional clinical justification.

Can I request an expedited appeal? Yes, both Cigna's internal appeals and Michigan DIFS external reviews offer expedited processes when delays would seriously jeopardize your health. Your physician must provide supporting documentation.

Does step therapy apply if I've tried DMTs outside Michigan? Yes, prior therapy trials from any location count toward step therapy requirements. Provide complete records from all treating physicians.

What happens if DIFS denies my external review? You may pursue judicial review in Michigan circuit court within 60 days of the DIFS decision, though this requires legal representation.

How do I find an in-network neurologist in Michigan? Use Cigna's online provider directory at cigna.com or call customer service. Look for neurologists with MS specialization and verify they're accepting new patients.

Can my doctor request a peer-to-peer review? Yes, your neurologist can request to speak directly with Cigna's medical director by calling 800-882-4462. This often helps resolve denials based on clinical criteria.

What if I need Ocrevus urgently? Your physician can request urgent PA by calling 800-882-4462 and attesting that standard timelines would seriously jeopardize your health. Decisions are made within 72 hours.

This article provides general information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan and clinical situation. For personalized guidance, consult your healthcare provider and review your plan documents. For insurance questions specific to Michigan, contact the Department of Insurance and Financial Services at 877-999-6442.

Sources & Further Reading

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