By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Cigna in Virginia: Complete Appeals Guide with Forms and Timelines

Quick Answer: Getting Ocrevus Covered by Cigna in Virginia

Ocrevus (ocrelizumab) requires prior authorization from Cigna and is typically dispensed through Accredo specialty pharmacy. Your neurologist must submit documentation proving MS diagnosis and, depending on your plan, may need to show you've tried other disease-modifying therapies first. If denied, Virginia law gives you strong appeal rights: internal appeals within 180 days, external review through the State Corporation Commission within 120 days, and step therapy override protections. Start today: Have your MS specialist initiate the prior authorization through Cigna's provider portal or call (855) 240-7408 for expedited processing.

Table of Contents

  1. Why Virginia State Rules Matter for Your Ocrevus Appeal
  2. Prior Authorization Requirements and Timelines
  3. Virginia's Step Therapy Protection Laws
  4. Continuity of Care During Plan Transitions
  5. Internal Appeals Process with Cigna
  6. External Review Through Virginia's Bureau of Insurance
  7. Practical Scripts for Calls and Appeals
  8. When Self-Funded Plans Are Different
  9. Quick Reference: Forms and Contacts

Why Virginia State Rules Matter for Your Ocrevus Appeal

Virginia's insurance laws provide crucial protections that work alongside Cigna's policies to ensure fair access to specialty medications like Ocrevus. Unlike federal ERISA plans, Virginia-regulated commercial insurance must follow strict timelines for prior authorization decisions and offer clear paths to override step therapy requirements.

Key Virginia protections include:

  • 72-hour decision timelines for urgent requests, 24 hours for emergent cases
  • Mandatory step therapy override criteria for MS patients
  • External review rights through the State Corporation Commission
  • Consumer assistance via the Managed Care Ombudsman

These rules apply to most Cigna commercial plans sold in Virginia, but not to self-funded employer plans (which we'll address later).

Prior Authorization Requirements and Timelines

Coverage at a Glance: Ocrevus with Cigna

Requirement Details Timeline Where to Submit
Prior Authorization Required for all Ocrevus coverage 72 hours (standard), 24 hours (urgent) Cigna Provider Portal
Prescriber Restriction Neurologist or MS specialist required N/A Include credentials in PA request
Pharmacy Network Accredo specialty pharmacy typically required N/A Verify with member services
Step Therapy May apply (plan-dependent) Override within 72 hours if criteria met Same portal as PA
Appeals Deadline 180 days from denial 30 days (pre-service), 60 days (post-service) Cigna appeals department

Step-by-Step: Fastest Path to Approval

  1. Contact your MS specialist to initiate prior authorization through Cigna's provider portal or by calling (855) 240-7408
  2. Gather required documentation: MS diagnosis confirmation, previous DMT trials and outcomes, current clinical status
  3. Submit complete PA request including medical necessity rationale citing FDA-approved indications
  4. Track status via Cigna member portal or by calling member services
  5. If denied, request peer-to-peer review within 72 hours while preparing formal appeal
  6. File internal appeal within 180 days if peer-to-peer unsuccessful
  7. Pursue external review through Virginia Bureau of Insurance if internal appeals fail

Virginia's Step Therapy Protection Laws

Virginia law (§38.2-3407.9:05) requires Cigna to override step therapy protocols when specific criteria are met. This is particularly important for MS patients who may have tried previous DMTs.

Medical Exception Criteria

Cigna must approve immediate access to Ocrevus if:

  • The required step therapy drug is contraindicated or would cause adverse reactions
  • You've already tried and failed the required drug under current or previous coverage
  • You're currently stable on Ocrevus with no clinical reason to change
  • The required drug would be ineffective based on your clinical characteristics
  • Your prescriber determines switching is not in your best medical interest

Documentation That Helps

When requesting a step therapy override, include these specific phrases and documentation:

  • "Patient has demonstrated intolerance to [specific DMT] as evidenced by [specific adverse events]"
  • "Previous trial of [drug name] resulted in disease progression as measured by [EDSS scores, MRI findings, relapse frequency]"
  • "Patient is currently stable on Ocrevus with no breakthrough disease activity"
  • Attach previous medication records, lab results showing adverse effects, or MRI reports showing progression

Continuity of Care During Plan Transitions

If you're switching to a new Cigna plan or transitioning from another insurer while on Ocrevus, Virginia law provides continuity protections. You may be entitled to:

  • Temporary coverage for up to 90 days while prior authorization is processed
  • Recognition of previous step therapy trials from other Virginia-regulated plans
  • Expedited review if interruption would cause clinical harm
Tip: Contact Cigna member services immediately when switching plans to request continuity of care provisions. Document your request in writing and keep records of all communications.

Internal Appeals Process with Cigna

Timeline Requirements

Cigna must respond to appeals within strict Virginia-mandated timeframes:

  • First-level appeal: 30 days for pre-service denials, 60 days for post-service
  • Second-level appeal: Same timeframes as first level
  • Urgent appeals: 72 hours maximum
  • Your deadline to appeal: 180 days from denial notice

Required Documentation for Medical Necessity Appeals

Your appeal letter must include:

  • Patient information and Cigna ID number
  • Specific denial details (claim number, date, reason)
  • Medical necessity justification referencing current MS treatment guidelines
  • Supporting clinical documentation (diagnosis codes, lab results, physician notes)
  • Specific relief requested (approval of Ocrevus coverage)
Clinician Corner: When writing medical necessity letters for Ocrevus, reference the FDA label indications, current AAN/ECTRIMS guidelines, and patient-specific factors like MRI lesion burden, disability progression, or previous DMT failures. Include specific ICD-10 codes (G35 for MS) and document contraindications to preferred alternatives.

External Review Through Virginia's Bureau of Insurance

If Cigna denies your internal appeals, Virginia provides independent external review through the State Corporation Commission Bureau of Insurance.

Filing Requirements

  • Deadline: 120 days from final internal denial
  • Required form: Form 216-A (External Review Request)
  • Eligible denials: Medical necessity, experimental treatment determinations
  • Filing fee: None (Virginia provides free external review)

Contact Information

Virginia State Corporation Commission Bureau of Insurance

  • Phone: (877) 310-6560 (toll-free) or (804) 371-9741
  • Email: [email protected]
  • Mailing Address: P.O. Box 1157, Richmond, VA 23218
  • Fax: (804) 371-9915

Review Timeline

  • Standard review: 45 days maximum
  • Expedited review: 72 hours (urgent), 6 business days (experimental treatment)
  • Additional documentation: You have 5 business days after acceptance to submit extra evidence

Practical Scripts for Calls and Appeals

Patient Phone Script for Cigna Member Services

"Hello, I'm calling about a prior authorization denial for Ocrevus for multiple sclerosis. My member ID is [number]. I'd like to request a peer-to-peer review with the medical director and understand my appeal rights under Virginia law. Can you also confirm whether step therapy applies and what the specific denial reason was?"

Clinic Staff Script for Peer-to-Peer Request

"I'm calling to request an urgent peer-to-peer review for [patient name] regarding Ocrevus coverage. The patient has relapsing MS with documented progression on previous DMTs. Under Virginia Code 38.2-3407.9:05, this should qualify for step therapy override. Can we schedule a clinical review with your medical director today?"

Email Template for Gathering Documentation

"Dear [Provider/Records Department], I need complete documentation for an insurance appeal for Ocrevus coverage, including: (1) MS diagnosis confirmation with ICD-10 codes, (2) previous DMT trial records with dates and outcomes, (3) current clinical status including recent MRI reports, (4) any adverse event documentation from previous treatments. Please provide within 5 business days as we have appeal deadlines. Thank you."

When Self-Funded Plans Are Different

Important limitation: If your Cigna coverage is through a large employer's self-funded plan, Virginia state protections may not apply. These ERISA-governed plans have different rules:

  • Federal external review through HHS instead of Virginia Bureau of Insurance
  • Different step therapy override criteria (if any)
  • Appeal timelines set by plan documents, not Virginia law

How to check: Look at your insurance card or Summary Plan Description. Self-funded plans often say "Administrative Services Only" or reference ERISA. When in doubt, call member services and ask directly.

Quick Reference: Forms and Contacts

Essential Forms and Portals

  • Cigna Provider Portal: Coverage and Claims
  • Member Services: 1-800-CIGNA24 (1-800-244-6224)
  • Prior Authorization Fax: (verify current number with provider services)
  • Virginia External Review Form 216-A: SCC Bureau of Insurance

Virginia Consumer Assistance

  • Managed Care Ombudsman: (877) 310-6560
  • Consumer Services: [email protected]
  • Life & Health Complaints: (804) 371-9691

Key Deadlines to Remember

  • Internal appeal: 180 days from denial
  • External review: 120 days from final internal denial
  • Step therapy override: 72 hours for Cigna response
  • Urgent appeals: 72 hours for Cigna response

When to Get Additional Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis and creates point-by-point responses aligned with each plan's own coverage rules, pulling appropriate citations from FDA labeling, peer-reviewed studies, and recognized treatment guidelines.

For complex denials or if you're uncomfortable navigating the appeals process alone, consider working with specialists who understand both Cigna's internal processes and Virginia's regulatory requirements. The platform helps ensure your appeal includes all required clinical facts, proper documentation, and meets procedural requirements while tracking deadlines.

From our advocates: "We've seen many Ocrevus denials overturned when the appeal clearly documents previous DMT failures and cites specific sections of the plan's own medical policy. The key is often showing that step therapy requirements have already been met through previous coverage or that the patient meets medical exception criteria under Virginia law."

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Ocrevus in Virginia? A: Standard requests: 72 hours. Urgent requests: 24 hours. If Cigna doesn't respond within these timeframes, coverage may be automatically approved under Virginia law.

Q: What if Ocrevus is not on my Cigna formulary? A: Request a formulary exception with medical necessity documentation. Your doctor must explain why formulary alternatives are inappropriate for your specific case.

Q: Can I get emergency Ocrevus while my appeal is pending? A: Yes, if your neurologist certifies that delay would seriously jeopardize your health. Request expedited appeal and contact Virginia Bureau of Insurance if Cigna doesn't respond within 72 hours.

Q: Do previous DMT trials with other insurers count for step therapy? A: Under Virginia law, yes. Cigna must consider previous trials and failures from other Virginia-regulated plans when evaluating step therapy requirements.

Q: What happens if my employer plan is self-funded? A: Virginia protections may not apply. You'll need to follow federal ERISA appeal procedures and may have external review through HHS instead of Virginia's Bureau of Insurance.

Q: Can I appeal if I'm denied due to not having tried Kesimpta first? A: Yes. Request step therapy override if you have contraindications to Kesimpta, have tried it previously, or your doctor determines it's not appropriate for your case.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and medical circumstances. Always consult with your healthcare provider about treatment decisions and contact Virginia's Bureau of Insurance or a qualified attorney for specific legal guidance regarding insurance appeals.

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