By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Humana in California: Complete Prior Authorization Guide

Quick Answer: Getting Ocrevus Covered by Humana in California

Ocrevus (ocrelizumab) requires prior authorization from Humana and is subject to step therapy requirements. Most patients must first try and fail preferred MS medications before approval. Submit your PA request through Humana's provider portal with complete clinical documentation. If denied, California residents can file an Independent Medical Review (IMR) through the DMHC, which has a 50-68% success rate for specialty drug appeals. Start today: Verify your plan covers Ocrevus under Medicare Part B, gather your MS diagnosis records and prior treatment history, then work with your neurologist to submit the prior authorization request.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You're Asked for More Information
  7. If Your Request is Denied
  8. California's Independent Medical Review Process
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This guide helps California patients with Humana Medicare Advantage or Medicare Part D plans navigate the prior authorization process for Ocrevus (ocrelizumab), a specialty medication for multiple sclerosis. You'll learn how to prepare a strong initial request, handle denials, and use California's robust appeal rights to get coverage approved.

Who this helps:

  • MS patients prescribed Ocrevus by their neurologist
  • Caregivers managing insurance appeals
  • Healthcare providers submitting PA requests
  • Anyone facing a Humana denial for MS medications

Before You Start: Verify Your Coverage

Check Your Plan Type

Ocrevus is covered under Medicare Part B (medical benefit), not Part D (pharmacy benefit), because it's administered by IV infusion in a clinical setting. Verify this with Humana member services at the number on your insurance card.

Confirm Formulary Status

According to Humana's 2025 formulary, Ocrevus is listed as a Preferred specialty drug but requires prior authorization and step therapy. Check your specific plan's coverage by using Humana's PA Search Tool.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required Must get approval before treatment Humana PA Lists
Step Therapy Try preferred drugs first 2025 Part B Step Therapy List
Specialty Drug Tier Higher copays/coinsurance Plan formulary document
Medicare Part B Coverage Infusion benefit, not pharmacy Member handbook

Gather What You Need

Essential Documentation

Clinical Records:

  • MS diagnosis confirmation with ICD-10 code (G35)
  • MRI reports showing lesions or disease activity
  • EDSS (Expanded Disability Status Scale) scores
  • Complete treatment history with dates and outcomes

Prior Therapy Documentation:

  • Names of previous DMTs tried
  • Duration of each treatment
  • Reason for discontinuation (lack of efficacy, side effects, contraindications)
  • Clinical evidence of failure (new relapses, MRI progression)

Required Lab Work:

  • Hepatitis B screening (HBsAg, anti-HBc, anti-HBs)
  • Complete blood count with differential
  • Immunization status (live vaccines must be completed before treatment)

Step Therapy Requirements

Humana typically requires trial and failure of these preferred MS medications first:

  • Injectable interferons (Avonex, Rebif, Betaseron)
  • Glatiramer acetate (Copaxone, Glatopa)
  • Oral DMTs (Tecfidera, Aubagio, Gilenya)
Note: If you've been on Ocrevus within the past 12 months with documented claims, you may be exempt from repeating step therapy.

Submit Your Prior Authorization Request

Step-by-Step Submission Process

  1. Access the PA Form
  2. Complete Medical Necessity Letter Your neurologist should include:
    • Confirmed MS diagnosis per McDonald criteria
    • Specific MS phenotype (relapsing-remitting, primary progressive, etc.)
    • Prior DMT failures with clinical evidence
    • Why Ocrevus is medically necessary for your case
    • Treatment goals and monitoring plan
  3. Submit Complete Package
    • Completed PA form
    • Medical necessity letter
    • Clinical records and lab results
    • Prior therapy documentation
    • Submit via provider portal or fax (verify current fax number on form)

Clinician Corner: Medical Necessity Checklist

Healthcare providers should ensure their letters include:

  • Problem statement: Clear MS diagnosis with supporting evidence
  • Prior treatments: Specific drugs tried, duration, and outcomes
  • Clinical rationale: Why alternatives aren't suitable
  • Guideline support: Reference to FDA labeling or AAN guidelines
  • Monitoring plan: How treatment response will be assessed

Follow-Up and Timelines

Expected Processing Times

  • Standard requests: Up to 30 days for Part B medical benefit decisions
  • Expedited requests: 72 hours if urgent medical need is documented
  • California requirement: Insurers must acknowledge receipt within 5 business days

When to Follow Up

Call Humana at 3-5 business days if you haven't received acknowledgment. Use this script:

"I'm calling to check on prior authorization request #[reference number] for Ocrevus submitted on [date]. Can you confirm it was received and provide the expected decision timeline?"

Document all calls with date, time, representative name, and reference numbers.

If You're Asked for More Information

Humana may request additional documentation for medical necessity. Common requests include:

  • More detailed treatment history
  • Recent MRI reports
  • Specialist consultation notes
  • Evidence of contraindications to preferred drugs

Respond promptly to avoid delays. If the request seems unreasonable, document it for potential appeal purposes.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Step therapy not completed Document all prior DMT trials with failure evidence
Insufficient medical necessity Provide detailed clinical rationale and guidelines
Missing lab work Submit required hepatitis B and CBC results
Incomplete prior therapy documentation Obtain records from all previous providers

Internal Appeal Process

  1. File within 65 days of denial notice
  2. Submit new evidence addressing denial reasons
  3. Request peer-to-peer review if initial appeal denied
  4. Document everything for potential external review
Tip: Many Humana denials are overturned on appeal when complete documentation is provided. Don't give up after the first denial.

California's Independent Medical Review Process

California offers powerful appeal rights through the Department of Managed Health Care (DMHC). For specialty drug appeals like Ocrevus, the success rate is 50-68%.

When to Use IMR

  • After exhausting Humana's internal appeals
  • If Humana fails to respond within required timeframes
  • For denials based on "not medically necessary"

How to File an IMR

  1. Complete internal appeals first (required step)
  2. Apply online at healthhelp.ca.gov or call 888-466-2219
  3. Submit within required timeframe (varies by situation)
  4. Include all documentation from your PA request and appeals

IMR Timeline and Process

  • Standard IMR: Decision within 45 days
  • Expedited IMR: Decision within 7 days for urgent cases
  • No cost to patient: California covers all IMR fees
  • Binding decision: Humana must comply if IMR rules in your favor

Organizations like Counterforce Health specialize in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical evidence to craft targeted rebuttals that address specific payer requirements.

Renewal and Re-Authorization

Planning for Ongoing Coverage

Ocrevus requires re-authorization every 6-12 months. Calendar these dates:

  • 90 days before current authorization expires
  • Submit renewal with updated clinical notes
  • Include treatment response evidence (stable/improved EDSS, MRI results)

What to Include in Renewals

  • Continued medical necessity
  • Treatment response documentation
  • Any new clinical developments
  • Updated lab work if required

Quick Reference Checklist

Before Starting:

  • Verify Part B coverage for infusions
  • Check formulary status and PA requirements
  • Confirm in-network infusion site

Documentation Needed:

  • MS diagnosis with ICD-10 code G35
  • Prior DMT trial and failure evidence
  • Hepatitis B screening results
  • Current MRI and clinical notes
  • Medical necessity letter from neurologist

Submission Process:

  • Complete Humana PA form
  • Submit via provider portal or fax
  • Document submission date and reference number
  • Follow up within 5 business days

If Denied:

  • File internal appeal within 65 days
  • Address specific denial reasons
  • Request peer-to-peer review
  • Consider California IMR if internal appeals fail

Frequently Asked Questions

How long does Humana prior authorization take for Ocrevus in California? Standard requests take up to 30 days for Part B coverage. Expedited requests can be processed within 72 hours if urgent medical need is documented.

What if Ocrevus isn't on my Humana formulary? Ocrevus is typically covered under Part B medical benefit, not formulary. If denied, you can request a formulary exception with supporting medical necessity documentation.

Can I get expedited approval for Ocrevus? Yes, if your neurologist documents urgent medical need (active relapse, rapid progression), request expedited review for 72-hour processing.

Does California's step therapy override law apply to Ocrevus? California has protections for step therapy, but Medicare plans follow federal rules. Document contraindications or failures of preferred drugs carefully.

What's the success rate for Ocrevus appeals in California? California's IMR process has a 50-68% success rate for specialty drug appeals when proper medical evidence is provided.

How much will Ocrevus cost with Humana coverage? As a specialty infusion under Part B, you'll typically pay 20% coinsurance after meeting your deductible. Costs vary by plan and supplemental coverage.

Can I use Genentech's patient assistance for Ocrevus? Yes, Genentech offers copay assistance and patient support programs. Check eligibility at their official website or ask your treatment center.

What happens if I move to another state while on Ocrevus? Your Humana coverage continues, but appeal rights may differ by state. California's IMR process is particularly robust compared to other states.

This guide provides educational information and should not replace professional medical or legal advice. Always consult with your healthcare provider and insurance plan for personalized guidance.

Need help with a complex appeal? Counterforce Health helps patients and providers turn insurance denials into successful appeals by creating evidence-backed rebuttals tailored to specific payer requirements.

California Resources:

  • DMHC Help Center: 888-466-2219
  • Online IMR application: healthhelp.ca.gov
  • Consumer assistance: Health Consumer Alliance

Sources & Further Reading

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