By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Cigna in North Carolina: Appeals Guide & Forms

Answer Box: Getting Ocrevus Covered by Cigna in North Carolina

Fastest path to approval: Submit prior authorization through your neurologist with documented MS diagnosis, prior DMT failure/intolerance, and hepatitis B screening. If denied, file internal appeal within 180 days, then external review through North Carolina's Smart NC within 120 days of final denial. Start today: Call your neurologist to verify all required documentation is complete and request peer-to-peer review if initially denied.

Table of Contents

  1. Understanding Your Cigna Coverage
  2. Prior Authorization Requirements
  3. Common Denial Reasons & How to Fix Them
  4. Step-by-Step Appeals Process
  5. North Carolina External Review Rights
  6. Templates & Scripts
  7. Cost-Saving Options
  8. When to Escalate
  9. FAQ

Understanding Your Cigna Coverage

Cigna typically manages Ocrevus (ocrelizumab) through their specialty pharmacy partner, Express Scripts/Accredo. This means your MS medication requires prior authorization and must be filled through their designated specialty pharmacy network.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Ocrevus requests Cigna provider portal or PA forms Cigna PA Requirements
Formulary Status Specialty tier medication Your plan's formulary document Plan-specific formulary
Step Therapy Must try/fail other DMTs first Cigna MS drug policy Cigna MS Coverage Policy
Specialty Pharmacy Must use Accredo or approved network Member services or EOB Cigna Specialty Pharmacy
Appeals Deadline 180 days from denial date Denial letter Internal Cigna policy

Prior Authorization Requirements

Cigna requires specific clinical documentation before approving Ocrevus. Your neurologist must demonstrate that you meet all medical necessity criteria.

Required Documentation

For All MS Types:

  • Confirmed MS diagnosis by a neurologist
  • Patient age 18 or older
  • Hepatitis B screening results (must be negative for active infection)
  • Monotherapy use (no other MS DMTs)
  • FDA-approved dosing schedule

For Relapsing MS (RRMS, CIS, Active SPMS):

  • Documentation of recent disease activity (relapses, MRI changes)
  • Trial and failure/intolerance of at least one other DMT
  • Clinical notes supporting inadequate response to previous therapy

For Primary Progressive MS:

  • Evidence of disability progression independent of relapses
  • EDSS score ≤6.5
  • Ability to ambulate more than 5 meters
  • Documented progression within the prior year
Tip: Ask your neurologist to reference Cigna's specific Ocrevus policy when submitting your PA to ensure all criteria are addressed.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No confirmed MS diagnosis Submit detailed neurologist notes MRI reports, clinical exam findings, diagnostic timeline
Insufficient prior therapy trials Document DMT history Pharmacy records, clinical notes on efficacy/tolerability
Missing hepatitis B screening Complete required labs HBsAg, anti-HBc, anti-HBs results
Combination therapy concern Confirm monotherapy use Current medication list, discontinuation dates
Age requirement not met Verify patient age Date of birth documentation
Non-specialist prescriber Transfer to neurologist Referral to MS specialist

Step Therapy Requirements

Most Cigna plans require documented failure or intolerance of first-line DMTs before approving Ocrevus. Acceptable prior therapies typically include:

  • Interferon beta products (Avonex, Betaseron, Rebif)
  • Glatiramer acetate (Copaxone, Glatopa)
  • Oral DMTs (Tecfidera, Gilenya, Aubagio)
  • Other injectable DMTs

What counts as "failure":

  • Breakthrough relapses while on therapy
  • MRI progression (new/enlarging lesions)
  • Disability progression despite treatment
  • Intolerable side effects requiring discontinuation
  • Medical contraindications to continued use

Step-by-Step Appeals Process

Level 1: Internal Appeal with Cigna

Timeline: Submit within 180 days of denial date Decision deadline: 30 days (72 hours for expedited) Who can appeal: Patient, authorized representative, or prescribing physician

  1. Gather your denial letter - Note the specific reason codes and deadline
  2. Collect supporting evidence - Medical records, lab results, prior therapy documentation
  3. Request peer-to-peer review - Call 1-800-882-4462 to schedule physician-to-physician discussion
  4. Submit written appeal - Include medical necessity letter from neurologist
  5. Track your case - Follow up weekly for status updates

Medical Necessity Letter Checklist

Your neurologist's appeal letter should include:

  • Patient identification: Name, DOB, member ID, diagnosis codes
  • Clinical presentation: MS type, disease activity, disability status
  • Prior treatments: Specific DMTs tried, duration, reasons for discontinuation
  • Medical necessity: Why Ocrevus is clinically appropriate
  • Guideline support: References to AAN guidelines or FDA labeling
  • Risk without treatment: Consequences of continued denial
Clinician Corner: Reference the American Academy of Neurology's MS treatment guidelines to support medical necessity arguments, particularly for aggressive or treatment-refractory disease.

Level 2: Second-Level Internal Appeal

If your first appeal is denied, Cigna offers a second-level review by a different medical director who wasn't involved in the initial decision.

Timeline: Request within 60 days of first-level denial Process: Similar documentation requirements as Level 1 Outcome: Final internal decision from Cigna

North Carolina External Review Rights

North Carolina offers robust external review protections through the Smart NC program, administered by the Department of Insurance.

Eligibility Requirements

  • You must have a state-regulated insurance plan (not self-funded ERISA plans)
  • Must complete Cigna's internal appeals process first
  • Denial must be based on medical necessity or experimental treatment determination
  • Submit within 120 days of final internal denial

How to Request External Review

  1. Download the form: NC External Review Request Form
  2. Gather required documents:
    • Completed request form
    • Final denial letter from Cigna
    • All medical records supporting your case
    • Copy of insurance card
  3. Submit to Smart NC:
    • Mail: Insurance Benefit System Administrators, PO Box 2917, Shawnee Mission, KS 66201-1317
    • Fax: 919-807-6865

Timeline and Process

  • Review for completeness: Smart NC verifies eligibility
  • Assignment to IRO: Independent medical review by qualified specialists
  • Decision timeline: 45 days for standard review, 72 hours for expedited
  • Binding decision: If approved, Cigna must provide coverage within 3 business days
Note: North Carolina's external review program has helped many patients access expensive specialty medications. While specific success rates aren't published, cases with strong clinical documentation and clear medical necessity have better outcomes.

For questions or assistance, contact Smart NC at 1-855-408-1212.

Templates & Scripts

Patient Phone Script for Cigna

"Hello, I'm calling about a prior authorization denial for Ocrevus. My member ID is [ID number]. I'd like to request a peer-to-peer review between my neurologist and your medical director. Can you help me schedule this and provide the direct number for my doctor to call?"

Clinic Staff Script for Peer-to-Peer

"I'm calling to schedule a peer-to-peer review for [patient name], member ID [number], regarding a denied Ocrevus prior authorization. The denial reason was [specific reason]. Dr. [name] would like to discuss the clinical necessity with your medical director. When is the earliest available time?"

Appeal Letter Template Opening

"I am writing to appeal the denial of prior authorization for Ocrevus (ocrelizumab) for my patient [name], member ID [number]. This medication is medically necessary for treating their confirmed multiple sclerosis based on the following clinical evidence..."

Cost-Saving Options

Even with insurance approval, Ocrevus can have significant out-of-pocket costs. Consider these assistance programs:

Manufacturer Support

  • Ocrevus Co-pay Program: May reduce monthly costs to $10 for eligible commercial insurance patients
  • Genentech Patient Foundation: Need-based assistance for uninsured or underinsured patients
  • Information: Visit Ocrevus.com/support or call 1-844-627-3887

State and Federal Programs

  • North Carolina Medicaid: Expanded coverage may be available starting 2024
  • Medicare Extra Help: For Medicare Part D beneficiaries
  • State Pharmaceutical Assistance Programs: Contact North Carolina DHHS

When to Escalate

If your appeals are unsuccessful, you have additional options in North Carolina:

File a Complaint with State Regulators

North Carolina Department of Insurance

  • Phone: 1-855-408-1212 (Smart NC)
  • Online: NCDOI Consumer Services
  • Address: 1201 Mail Service Center, Raleigh, NC 27699-1201

What to Include in Your Complaint

  • Timeline of denial and appeals
  • All correspondence with Cigna
  • Medical records supporting necessity
  • Evidence of procedural violations or delays
  • North Carolina Legal Aid: For low-income patients
  • Patient Advocate Foundation: National nonprofit providing case management
  • MS Society: Disease-specific advocacy and resources

FAQ

How long does Cigna prior authorization take in North Carolina? Standard PA decisions are made within 14 days, with expedited reviews completed in 72 hours. Appeals have 30-day timelines unless marked urgent.

What if Ocrevus is non-formulary on my Cigna plan? You can request a formulary exception through the same prior authorization process. Your neurologist must demonstrate medical necessity and why formulary alternatives aren't appropriate.

Can I request an expedited appeal if my MS is worsening? Yes. If delay in treatment could seriously jeopardize your health, request expedited review. Both Cigna internal appeals and NC external review offer expedited pathways.

Does step therapy apply if I've failed DMTs outside North Carolina? Yes. Document all prior therapies regardless of where you received them. Pharmacy records and physician notes from other states are acceptable evidence.

What happens if Smart NC denies my external review? The IRO decision is final for the administrative process. You may still have legal options, but should consult with an attorney experienced in health insurance law.

How do I know if my plan is eligible for North Carolina external review? Most individual and small group plans are state-regulated and eligible. Large employer plans may be self-funded ERISA plans and not subject to state external review. Check with your HR department or call Smart NC to verify eligibility.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-based strategies tailored to each payer's specific requirements. Their platform analyzes denial letters, identifies the exact approval criteria, and generates targeted rebuttals that address payer policies point-by-point.

For complex cases like Ocrevus appeals, having expert support can significantly improve your chances of approval. Counterforce Health's team understands Cigna's specific requirements and North Carolina's appeals landscape, helping you navigate the process more effectively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Insurance policies and state regulations may change, so verify current requirements with official sources.

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