By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (ocrelizumab) Covered by Humana in New York: Prior Authorization Guide and Appeal Process

Quick Answer: Getting Ocrevus Covered by Humana in New York

Ocrevus (ocrelizumab) requires prior authorization from Humana and is typically covered under Medicare Part B when administered as an infusion. The fastest path to approval: (1) Ensure your neurologist documents confirmed MS diagnosis using McDonald criteria with supporting MRI evidence, (2) Complete required HBV screening and update vaccinations, and (3) Submit prior authorization through Humana's provider portal with detailed medical necessity documentation. If denied, you have 65 days to appeal through Medicare's federal appeals process—not New York State's external review system.

Table of Contents

Humana's Coverage Policy for Ocrevus

Ocrevus is classified as a specialty tier medication on Humana formularies, typically placed on Tier 5 or the highest specialty tier. The medication is covered under Medicare Part B when administered as an intravenous infusion in approved medical settings, not under Medicare Part D pharmacy benefits.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all Humana plans Humana PA Portal
Formulary Tier Specialty Tier (Tier 5) Plan-specific formulary
Coverage Type Medicare Part B (medical benefit) Medicare guidelines
Specialty Pharmacy Required through Humana network Humana Provider Resources
Appeals Deadline 65 days from denial notice Medicare Appeals Process

Prior Authorization Requirements

Diagnostic Criteria

Your neurologist must document a definitive diagnosis of multiple sclerosis based on the McDonald criteria, including:

  • MRI evidence showing lesions in at least two of five regions: periventricular, juxtacortical/intracortical, infratentorial, spinal cord, or optic nerve
  • Dissemination in space and time demonstrated through imaging or clinical progression
  • Exclusion of MS mimics through appropriate testing

For primary progressive MS (PPMS), additional requirements include an EDSS score between 3.0 and 6.5 and ability to ambulate more than 5 meters.

Required Screening and Vaccinations

Before starting Ocrevus, you must complete:

  1. Hepatitis B screening (HBsAg and anti-HBc) - mandatory for all patients
  2. Updated vaccinations, especially live vaccines given 4-6 weeks before treatment
  3. Baseline laboratory work as determined by your provider
Important: Patients with evidence of past or chronic HBV infection require consultation with a hepatologist before approval.

Medical Necessity Documentation

Clinician Requirements

Your prescribing neurologist must provide comprehensive documentation including:

  • Confirmed MS diagnosis with supporting MRI reports
  • Prior treatment history and outcomes (if step therapy applies)
  • Clinical rationale for choosing Ocrevus over alternatives
  • Contraindications to preferred therapies (if applicable)
  • Treatment goals and expected outcomes

Supporting Evidence

Strong prior authorization requests typically include:

  • Recent MRI reports showing active disease or progression
  • Documentation of relapse history or disability progression
  • References to FDA labeling and MS treatment guidelines
  • Justification for infusion site selection

Step Therapy and Exceptions

Humana may require step therapy, meaning you must try lower-cost disease-modifying therapies (DMTs) before Ocrevus approval. However, step therapy can be bypassed if your provider documents:

  • Medical contraindications to preferred agents
  • Previous intolerance or adverse reactions
  • Inadequate response to first-line treatments
  • Clinical urgency requiring immediate access to Ocrevus

Site of Care and Specialty Pharmacy Requirements

Infusion Site Restrictions

Ocrevus must be obtained through a Humana-contracted specialty pharmacy and administered at approved sites:

  • Preferred sites: Outpatient infusion centers, physician offices, ambulatory infusion suites
  • Hospital outpatient infusions may require additional prior authorization and clinical justification
  • Home infusion may be available when clinically appropriate

Specialty Pharmacy Process

  1. Your provider sends the prescription to a Humana network specialty pharmacy
  2. The specialty pharmacy coordinates benefit verification and prior authorization
  3. Medication is shipped to your designated infusion site
  4. Regular re-evaluations may be required for continued coverage

Appeals Process for Humana Medicare Advantage

Important: As a Humana Medicare Advantage member, you use the federal Medicare appeals process, not New York State's external review system.

Step-by-Step Appeal Process

  1. File Internal Appeal (Level 1)
    • Deadline: 65 days from denial notice
    • Submit through Humana member portal or by phone at 800-867-6601
    • Include supporting medical documentation
  2. Independent Review Entity (Level 2)
    • Automatic if Level 1 is denied
    • Independent Medicare contractor reviews your case
    • Timeline: 30 days for standard, 72 hours for expedited
  3. Administrative Law Judge (Level 3)
    • Available if previous levels deny coverage
    • Must meet minimum dollar threshold requirements

Expedited Appeals

Request expedited review if waiting for a standard decision could seriously harm your health. Your provider must certify the urgency, and decisions are made within 72 hours.

Common Denial Reasons and Solutions

Denial Reason Solution
Incomplete MS diagnosis Provide MRI reports meeting McDonald criteria
Missing HBV screening Complete required blood work before resubmission
Step therapy not attempted Document contraindications or previous failures
Non-preferred infusion site Justify medical necessity for hospital-based infusion
Insufficient medical necessity Include detailed provider letter with clinical rationale

Cost Support Options

Manufacturer Programs

  • Ocrevus Co-pay Program: May reduce out-of-pocket costs for eligible patients
  • Genentech Access Solutions: Provides financial assistance and insurance navigation
  • Patient navigators: Available through Ocrevus patient support

Additional Resources

  • Medicare Part B typically covers 80% after deductible
  • Supplemental insurance may cover remaining costs
  • Foundation grants may be available for qualifying patients
From our advocates: We've seen cases where initial denials were overturned simply by resubmitting with complete HBV screening results and a detailed neurologist letter explaining why the patient's specific MS phenotype requires Ocrevus rather than alternative DMTs. Thoroughness in the initial submission often prevents lengthy appeals.

FAQ

How long does Humana prior authorization take for Ocrevus? Standard prior authorization decisions are typically made within 30 days. Humana is working toward 95% of electronic requests being processed within one business day by 2026.

What if Ocrevus isn't on my Humana formulary? You can request a formulary exception through Humana's drug exception process, which requires physician documentation of medical necessity.

Can I use New York State's external appeal process? No. As a Medicare Advantage member, you must use the federal Medicare appeals process, not New York State's external review system.

Does step therapy always apply? Step therapy requirements vary by plan, but can be bypassed with proper medical justification for contraindications or previous treatment failures.

What happens if my appeal is denied at all levels? You may pursue further appeals through the Medicare Appeals Council and potentially Federal District Court if dollar thresholds are met.

How do I find a Humana-contracted specialty pharmacy? Contact Humana member services or ask your provider to verify network specialty pharmacies in your area.

When Coverage Gets Complex: Expert Support

Getting specialty medications like Ocrevus approved can be challenging, especially when denials occur. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis—whether it's prior authorization criteria, step therapy, or "not medically necessary"—and drafts point-by-point responses aligned to the plan's own rules, pulling the right clinical evidence and regulatory citations to support your case.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance issues in New York, contact Community Health Advocates at 888-614-5400 or visit the New York Department of Financial Services for additional consumer resources.

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