By Counterforce Health Team in Ocrevus (ocrelizumab) —

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

Answer Box: Getting Ocrevus Covered by Cigna in Ohio

Fastest path to approval: Submit Cigna's Ocrevus CCRD Prior Authorization Form via CoverMyMeds or fax (855) 840-1678. Include MS diagnosis (ICD-10), prior DMT failures, and clinical rationale. Standard review takes 5 business days; urgent cases call 800-882-4462. If denied, file internal appeal within 180 days, then external review through Ohio Department of Insurance (1-800-686-1526). Cigna prefers Accredo Specialty Pharmacy for fulfillment.

Table of Contents

  1. Start Here: Verify Your Plan
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Specialty Pharmacy Setup
  5. Support Lines and Case Management
  6. Appeals Process in Ohio
  7. Common Denial Reasons and Solutions
  8. Costs and Patient Assistance
  9. Frequently Asked Questions

Start Here: Verify Your Plan

Before starting your Ocrevus (ocrelizumab) prior authorization, confirm your Cigna coverage details:

Check your benefits:

  • Log into cigna.com or call the member services number on your ID card
  • Verify Ocrevus is covered under your prescription benefit
  • Confirm whether Express Scripts manages your pharmacy benefits
  • Note your formulary tier and any quantity limits

Key coverage details for Ohio residents:

  • Most Cigna plans require prior authorization for Ocrevus
  • Specialty drugs typically route through Accredo Specialty Pharmacy
  • Step therapy may apply depending on your specific plan
  • Site of care restrictions may favor outpatient infusion centers over home administration
Tip: If you have a Cigna Medicare Advantage plan, some requirements may differ from commercial coverage. Always verify with your specific plan documents.

Required Forms and Documentation

Primary Form: Ocrevus CCRD Prior Authorization

Download the Ocrevus CCRD Prior Authorization Form from Cigna's resource library. This national form applies to all states, including Ohio.

Required information:

  • Patient demographics and Cigna ID number
  • Prescriber NPI and specialty certification
  • Diagnosis with ICD-10 codes (G35 for multiple sclerosis)
  • Requested dose: Ocrevus 300 mg/10 mL vial
  • J-code for billing: J2350
  • Site of administration preference

Supporting Documentation Checklist

Your healthcare provider should include:

Clinical documentation:

  • MS diagnosis confirmation with MRI reports
  • Prior disease-modifying therapy (DMT) trials and outcomes
  • Documentation of treatment failures or intolerances
  • Current neurological status and EDSS scores if available
  • Hepatitis B screening results (required before starting)

Administrative requirements:

  • Prescriber attestation of medical necessity
  • Insurance verification and benefits check
  • Prior authorization for infusion site if applicable
Note: For continuation therapy, patients must have received at least one year of Ocrevus treatment to qualify for simplified renewal.

Submission Portals and Methods

Preferred: Electronic Submission

CoverMyMeds (Recommended):

SureScripts Integration:

  • Submit directly through your EHR system
  • Fastest processing for practices with integrated systems
  • Automatic status updates

Alternative: Fax and Phone

Standard fax: (855) 840-1678

  • Include cover sheet with patient name and Cigna ID
  • Confirm receipt within 24-48 hours
  • Standard processing: 5 business days

Urgent requests: Call 800-882-4462

  • Use when standard timeframe risks patient health
  • Peer-to-peer review available for complex cases
  • Expedited decisions within 24-72 hours

Specialty Pharmacy Setup

Accredo Specialty Pharmacy (Cigna Preferred)

Once your prior authorization is approved, Cigna typically directs Ocrevus to Accredo:

Contact information:

  • Phone: 866-759-1557 (patient enrollment)
  • Fax: 888-302-1028 (prescriptions)
  • NCPDP: 4436920
  • Address: 1620 Century Center Pkwy, Memphis, TN 38134-8822

Enrollment process:

  1. Accredo contacts patient within 24-48 hours of approval
  2. Verify insurance benefits and copay responsibility
  3. Schedule delivery or coordinate with infusion center
  4. Provide injection training if using Ocrevus Zunovo (subcutaneous)

What to expect:

  • Temperature-controlled shipping for IV formulation
  • Coordination with your infusion center for scheduling
  • Refill reminders before each 6-month dose
  • 24/7 clinical support line for questions

Support Lines and Case Management

Cigna Member Services

General member services: Number on your Cigna ID card

  • Verify benefits and prior authorization status
  • Check claims processing and appeals
  • Request formulary exception information

Provider services: 800-882-4462

  • Prior authorization status inquiries
  • Peer-to-peer review requests
  • Urgent determination requests

Manufacturer Support

OCREVUS CONNECTS® Patient Support:

  • Phone: 1-844-OCREVUS (627-3887)
  • Copay assistance program enrollment
  • Insurance navigation support
  • Treatment adherence resources

What they can help with:

  • Copay reduction (eligible patients may pay as little as $5 per dose)
  • Prior authorization letter templates
  • Appeals assistance and documentation
  • Connection to financial assistance programs

Appeals Process in Ohio

If your initial prior authorization is denied, Ohio residents have robust appeal rights through both Cigna's internal process and state external review.

Internal Appeals with Cigna

First-level internal appeal:

  • File within 180 days of denial notice
  • Submit via Cigna appeals portal or fax
  • Include new clinical evidence supporting medical necessity
  • Decision within 30 days (expedited: 72 hours)

Required documentation for appeals:

  • Original denial letter
  • Updated medical records showing disease progression
  • Peer-reviewed literature supporting Ocrevus use
  • Letter of medical necessity from treating neurologist

Ohio External Review Process

If Cigna denies your internal appeal, you can request an independent external review through the Ohio Department of Insurance.

Timeline and process:

  • Request external review within 180 days of final Cigna denial
  • Contact Ohio Department of Insurance: 1-800-686-1526
  • Complete "Request for Review by the Ohio Department of Insurance Form"
  • Independent Review Organization (IRO) conducts medical review

What makes Ohio consumer-friendly:

  • Ohio DOI can override insurer claims that a case isn't eligible for external review
  • Standard review: 30 days; expedited: 72 hours
  • IRO decision is binding on Cigna
  • No cost to the patient for external review
From our advocates: We've seen Ohio external reviews succeed when patients provide comprehensive documentation showing how Ocrevus fits their specific MS phenotype and why alternative DMTs aren't suitable. The key is demonstrating medical necessity through current treatment guidelines, not just physician preference.

Common Denial Reasons and Solutions

Denial Reason How to Address Required Documentation
No confirmed MS diagnosis Provide definitive diagnostic workup MRI reports, CSF analysis, McDonald criteria documentation
Insufficient prior therapy trials Document previous DMT failures Treatment records showing inadequate response or intolerance
Missing safety screening Complete required testing Hepatitis B panel, immunoglobulin levels, CBC with differential
Step therapy requirement Request medical exception Clinical rationale why first-line therapies are inappropriate
Site of care restriction Justify administration setting Medical necessity for specific infusion location

Medical Necessity Letter Template

Your neurologist should address these key points:

  1. MS phenotype and activity: Relapsing-remitting, secondary progressive, or primary progressive with evidence of activity
  2. Prior treatment history: Specific DMTs tried, duration, reasons for discontinuation
  3. Clinical rationale: Why Ocrevus is medically necessary for this patient
  4. Guideline support: Reference to AAN, ECTRIMS, or NMSS treatment recommendations
  5. Monitoring plan: Safety assessments and follow-up schedule

Costs and Patient Assistance

Insurance Coverage

Typical Cigna coverage:

  • Specialty tier copay (often $100-500 per infusion)
  • May require 20% coinsurance for high-deductible plans
  • Annual out-of-pocket maximum applies

Patient Assistance Programs

Genentech Patient Foundation:

  • Income-based assistance for uninsured/underinsured patients
  • Application through genentech-access.com
  • May cover up to 100% of drug cost for qualified patients

OCREVUS CONNECTS® Copay Program:

  • Reduces copay to as low as $5 per dose
  • Available for commercially insured patients
  • Not valid for government insurance (Medicare, Medicaid)

Frequently Asked Questions

How long does Cigna prior authorization take for Ocrevus in Ohio? Standard review is 5 business days via electronic submission, up to 15 days for fax submissions. Urgent requests are processed within 24-72 hours when health is at risk.

What if Ocrevus isn't on my Cigna formulary? Request a formulary exception through your physician. Cigna reviews these within 72 hours and requires clinical justification for why formulary alternatives aren't appropriate.

Can I appeal if I'm denied for step therapy requirements? Yes. Your physician can request a step therapy override by documenting why first-line treatments would be ineffective or harmful based on your medical history and current condition.

Does Cigna cover both IV Ocrevus and subcutaneous Ocrevus Zunovo? Both formulations typically require prior authorization. Ocrevus Zunovo may have additional requirements for home administration training and safety monitoring.

What's the difference between internal and external appeals in Ohio? Internal appeals are reviewed by Cigna's medical staff. External appeals go to an independent medical expert through Ohio's Department of Insurance and are binding on the insurer.

How do I transfer my prescription to Accredo? Your physician can e-prescribe directly to Accredo (NCPDP 4436920) or fax to 888-302-1028. Accredo will contact you within 48 hours to coordinate delivery and infusion scheduling.

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeals processes for specialty medications like Ocrevus. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific coverage criteria. By combining payer-specific workflows with the right clinical evidence, we help turn insurance denials into approvals while saving time for healthcare teams. Learn more at www.counterforcehealth.org.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice or a guarantee of coverage. Always consult with your healthcare provider about treatment decisions and verify current coverage details with your insurance plan. For personalized assistance with Ohio insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526 or visit insurance.ohio.gov.

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