By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (ocrelizumab) Covered by Cigna in Texas: Prior Authorization, Appeals, and Billing Codes

Answer Box: Getting Ocrevus (ocrelizumab) Covered by Cigna in Texas

Cigna requires prior authorization for Ocrevus (ocrelizumab) with step therapy for relapsing MS forms and specific criteria for primary progressive MS. Your neurologist submits a PA request through Cigna's provider portal or fax (855-840-1678) with hepatitis B screening, MS diagnosis confirmation, and prior DMT failure documentation. If denied, you have 180 days to file an internal appeal, followed by external review through Texas Department of Insurance. First step today: Contact your neurologist to gather prior therapy records and hepatitis B labs before submitting the PA request.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Multiple Sclerosis
  3. Product Coding: HCPCS, J-Codes, and NDC Numbers
  4. Clean Prior Authorization Request
  5. Frequent Coding and Billing Pitfalls
  6. Verification with Cigna Resources
  7. Quick Audit Checklist
  8. Appeals Process in Texas
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Ocrevus (ocrelizumab) typically falls under the medical benefit when administered as an IV infusion in physician offices or outpatient infusion centers. The newer subcutaneous version, Ocrevus Zunovo, may be covered under either medical or pharmacy benefits depending on your specific Cigna plan.

Benefit Type Setting Coding Method Common Requirements
Medical Benefit Physician office, infusion center J-code + administration CPT + NDC Prior authorization, site of care restrictions
Pharmacy Benefit Home infusion, some retail NDC with per diem codes Quantity limits, specialty pharmacy requirement

Most Cigna plans process Ocrevus through the medical benefit using buy-and-bill methodology, where your provider purchases the medication and bills Cigna directly.

ICD-10 Mapping for Multiple Sclerosis

Starting October 1, 2025, new ICD-10 codes provide greater specificity for multiple sclerosis documentation. These codes are crucial for prior authorization approval and proper billing.

Key MS Codes for Ocrevus

Code Description When to Use
G35.A Relapsing-remitting multiple sclerosis RRMS, CIS, active SPMS
G35.B1 Active primary progressive MS PPMS with current activity
G35.B2 Non-active primary progressive MS PPMS without current activity
G35.D Multiple sclerosis, unspecified Avoid - may trigger payer requests
Documentation Tip: Include specific disease course details in clinical notes to justify subcategory selection. Vague documentation defaults to G35.D, which may cause coverage delays.

Product Coding: HCPCS, J-Codes, and NDC Numbers

HCPCS J-Codes

  • J2350: Ocrevus (ocrelizumab) - 1 mg units
  • J2351: Ocrevus Zunovo (ocrelizumab/hyaluronidase-ocsq) - 1 mg units (effective April 1, 2025)

Billing Units Calculation

Initial Treatment (Two-dose series):

  • Day 1: 300 units (300 mg)
  • Day 15: 300 units (300 mg)

Maintenance Dosing:

  • Every 6 months: 600 units (600 mg)

NDC Numbers

Product 10-Digit NDC 11-Digit NDC
Ocrevus 300 mg vial 50242-0150-01 50242-150-01
Ocrevus Zunovo 920 mg 50242-0554-01 50242-554-01

Administration CPT Codes

IV Infusion (Medical Benefit):

  • 96413: Initial infusion ≤1 hour
  • 96415: Each additional hour
  • Alternative: 96365/96366 if payer rejects chemotherapy codes

Subcutaneous (Zunovo):

  • 96401: Non-hormonal anti-neoplastic injection

Clean Prior Authorization Request

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's own rules.

Required Documentation for Cigna PA

All Patients:

  • Confirmed MS diagnosis by neurologist
  • Patient age ≥18
  • Negative hepatitis B screening results
  • Monotherapy use (no concurrent DMTs)
  • FDA-approved dosing schedule

Relapsing MS (RRMS, CIS, active SPMS):

  • Documentation of ≥1 prior DMT trial with failure or intolerance
  • Recent disease activity evidence (relapses or MRI changes)
  • Clinical notes detailing inadequate response to prior therapy

Primary Progressive MS (PPMS):

  • EDSS score ≤6.5
  • Ability to ambulate >5 meters
  • Documented disease progression within the prior year

Submission Process

Standard Timeline: 14 days for PA decision Expedited Timeline: 72 hours if condition seriously jeopardizes health

Submit via:

  • Cigna provider portal
  • Fax: 855-840-1678
  • Phone for urgent cases: 800-882-4462

Frequent Coding and Billing Pitfalls

Common Errors to Avoid

  1. Incorrect Unit Calculation: Always bill in 1 mg units (300 units = 300 mg, not 3 units)
  2. Wrong NDC Format: Verify if your billing system requires 10-digit or 11-digit NDC
  3. Missing JZ Modifier: Use when drug is discarded due to patient size or reaction
  4. Outdated ICD-10 Codes: Update systems for October 2025 MS code changes
  5. Same-Day Billing Issues: May require modifiers or separate E&M documentation

Documentation Requirements

Include in clinical notes:

  • Specific MS phenotype and activity status
  • Prior DMT names, duration, and reasons for discontinuation
  • Hepatitis B screening results and dates
  • Current EDSS score (for PPMS)
  • Treatment goals and monitoring plan

Verification with Cigna Resources

Before submitting claims or PA requests, verify current requirements through official Cigna channels:

  1. Provider Portal: Check member-specific formulary status and PA requirements
  2. Cigna Coverage Policies: Review ocrelizumab policy IP_0212 for current criteria
  3. Express Scripts: Confirm specialty pharmacy requirements if applicable
  4. CoverMyMeds: Use for electronic PA submission with real-time status updates
Important: Policies update regularly. Always verify current requirements before submission.

Quick Audit Checklist

Before Submitting PA or Claim:

  • Correct ICD-10 code for specific MS type
  • Appropriate J-code (J2350 for Ocrevus, J2351 for Zunovo)
  • Accurate NDC number format
  • Proper unit calculation (mg = units)
  • Required modifiers (JZ if drug discarded)
  • Complete hepatitis B screening documentation
  • Prior DMT failure documentation (for relapsing MS)
  • Neurologist prescription or consultation
  • Patient age verification (≥18)
  • Monotherapy confirmation

Appeals Process in Texas

If your Ocrevus prior authorization is denied, Texas law provides strong appeal rights with specific timelines.

Internal Appeal Process

Timeline: File within 180 days of denial Processing: Up to 45 days (expedited: 72 hours) Requirements: Written request with supporting documentation

Submit to Cigna with:

  • Copy of denial letter
  • Medical necessity letter from neurologist
  • Complete medical records supporting MS diagnosis
  • Documentation of prior therapy failures
  • Request for peer-to-peer review if appropriate

External Review (Texas IRO)

After exhausting internal appeals, Texas residents can request independent external review through the Texas Department of Insurance.

Timeline: Within 4 months of final internal denial Processing: 20 days standard, 5 days for urgent cases Cost: Free to patient (insurer pays IRO fees) Decision: Binding if approved

Contact Information:

  • Texas Department of Insurance: 1-800-252-3439
  • IRO Information Line: 1-866-554-4926
Texas Advantage: The state's expedited external review process is particularly beneficial for specialty drug appeals where treatment delays could worsen MS symptoms.

When working with Counterforce Health, patients and clinicians get access to payer-specific workflows and templates that meet procedural requirements while tracking deadlines and required documentation attachments.

FAQ

How long does Cigna prior authorization take for Ocrevus in Texas? Standard PA decisions are made within 14 days. Expedited reviews for urgent cases are completed within 72 hours.

What if Ocrevus is non-formulary on my Cigna plan? Request a formulary exception through your physician, providing clinical rationale why formulary alternatives are unsuitable for your specific MS type.

Can I request an expedited appeal in Texas? Yes, if treatment delay would seriously jeopardize your health or ability to function. Mark requests as "urgent" and include supporting clinical documentation.

Does step therapy apply if I've failed DMTs outside Texas? Yes, Cigna's step therapy requirements apply regardless of where prior treatments were tried. Ensure complete documentation of previous therapy failures.

What happens if my appeal is denied? After exhausting internal appeals, you can request external review through Texas Department of Insurance. The IRO decision is binding if they approve coverage.

How do I get help with the appeals process? Contact Texas Department of Insurance (1-800-252-3439), Office of Public Insurance Counsel (1-877-611-6742), or Disability Rights Texas for assistance with complex appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may vary by plan and change over time. Always verify current requirements with Cigna and consult with your healthcare provider regarding appropriate treatment decisions. For personalized assistance with insurance appeals, consider consulting with healthcare advocates or legal professionals familiar with Texas insurance law.

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