By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Humana in North Carolina: Appeals Guide, Forms & Templates

Answer Box: Getting Ocrevus Covered by Humana in North Carolina

Humana requires prior authorization for Ocrevus (ocrelizumab) and may require step therapy (trying other MS drugs first). The fastest path to approval: 1) Submit PA through Humana's provider portal with complete MS documentation, 2) Request peer-to-peer review if initially denied, 3) File internal appeal within 60 days if needed. Note: Medicare Advantage members cannot use North Carolina's Smart NC external review—they must follow federal CMS appeals. Start by verifying your specific plan requirements and gathering your MS diagnosis records, prior therapy history, and hepatitis B screening results.

Table of Contents

Understanding Humana's Ocrevus Coverage

Ocrevus (ocrelizumab) is a specialty biologic approved for both relapsing forms of multiple sclerosis and primary progressive MS. Humana covers Ocrevus under Medicare Part B (not Part D) when administered as an infusion, using HCPCS code J2350.

Coverage Requirements at a Glance

Requirement Details Where to Find
Prior Authorization Required for all Humana plans Humana PA Lists
Formulary Status Preferred specialty drug (Part B) Humana Drug Lists
Step Therapy May require trial of other DMTs Plan-specific; verify with Humana
Site of Care Physician office or infusion center Part B coverage criteria
Diagnosis Codes G35 (multiple sclerosis) ICD-10 required

For 2024-2025, Humana lists Ocrevus as "preferred" but step therapy requirements still apply based on individual plan policies. This means you may need documented trials and failures of other disease-modifying therapies before approval.

Reading Your Denial Letter

When Humana denies Ocrevus, look for these key elements in your denial notice:

  • Denial reason code (medical necessity, step therapy, missing documentation)
  • Appeal deadline (typically 60 days for Medicare Advantage)
  • Required documentation for reconsideration
  • Peer-to-peer review option (usually 5-10 days to request)
Tip: Save all denial letters and correspondence. You'll need reference numbers and dates for appeals.

Common Fixable Issues

Before filing a formal appeal, check if your denial stems from easily correctable issues:

Missing Documentation:

  • MS diagnosis confirmation with MRI reports
  • Prior therapy trials with dates and outcomes
  • Hepatitis B screening results
  • Current neurological assessment

Coding Problems:

  • Wrong diagnosis code (ensure G35 is used)
  • Incorrect HCPCS code (should be J2350)
  • Missing prior authorization request

Policy Misunderstandings:

  • Submitted as Part D instead of Part B
  • Incorrect site of care designation
  • Missing step therapy documentation

Step-by-Step: Fastest Path to Approval

1. Gather Required Documents (Patient/Clinic)

  • Insurance card and member ID
  • Complete MS diagnosis with MRI evidence
  • List of prior DMT trials with dates and outcomes
  • Hepatitis B screening and vaccination records
  • Recent neurological examination notes

Timeline: 1-2 days | Submit via: Your neurologist's office

2. Submit Prior Authorization (Clinic)

Use Humana's provider portal or Availity. Include all documentation from step 1.

Timeline: Same day submission | Expected response: 5-14 business days

3. Request Peer-to-Peer if Denied (Physician)

Call Humana within 5-10 days of denial notice to schedule consultation with clinical reviewer.

Timeline: Must request quickly | Decision: Often same-day

4. File Internal Appeal if Still Denied (Patient/Physician)

Submit formal appeal with medical necessity letter and supporting evidence.

Timeline: Within 60 days of denial | Decision: 30 days (standard) or 72 hours (expedited)

5. External Review (Commercial Plans Only)

Important: Medicare Advantage members cannot use North Carolina's Smart NC external review. Commercial plan members can file with Smart NC.

Timeline: Within 120 days | Decision: 45 days (standard) or 72 hours (expedited)

First-Level Appeal Process

For Medicare Advantage Members

Submit your appeal through Humana's member portal or mail to the address on your denial letter. Include:

  • Completed appeal form
  • Copy of original denial
  • Medical necessity letter from physician
  • Supporting clinical documentation
  • Any additional evidence (guidelines, studies)

Deadline: 60 days from denial date Decision timeline: 30 days (standard) or 72 hours (expedited)

For Commercial Plan Members

Follow the same process, but you'll have additional external review rights through North Carolina's Smart NC program if your internal appeal is denied.

Peer-to-Peer Review

What it is: A phone consultation between your neurologist and a Humana clinical reviewer to discuss medical necessity.

How to request: Your physician calls Humana's provider services line within 5-10 days of denial (exact timeline specified in denial letter).

Preparation checklist:

  • Have patient chart and MRI reports ready
  • Prepare summary of prior therapy failures
  • Review current MS treatment guidelines
  • Document functional impairment or progression
From our advocates: We've seen peer-to-peer reviews successfully overturn denials when physicians clearly articulate why alternatives failed and cite specific guideline recommendations. The key is being prepared with concrete clinical rationale, not just requesting the drug because it's newer.

Second-Level Appeals & External Review

Medicare Advantage: Federal Appeals Process

If your internal Humana appeal is denied, you can escalate to an Independent Review Entity (IRE) through the federal CMS process. This is not the same as North Carolina's Smart NC program.

Process:

  1. Follow instructions in your denial letter
  2. Submit to the designated IRE (usually MAXIMUS Federal Services)
  3. Include all previous documentation plus any new evidence

Commercial Plans: Smart NC External Review

North Carolina residents with fully insured commercial plans can use the state's external review process through Smart NC.

Key benefits:

  • Free expert advocacy support
  • Binding decisions on insurers
  • Expedited review for urgent cases (72-hour decisions)
  • High success rates for specialty drug appeals

Contact Smart NC: 1-855-408-1212

Medical Necessity Letter Template

Your neurologist should include these elements in the appeal letter:

[Date]
[Insurance Appeals Department]

RE: Appeal for Ocrevus (ocrelizumab), Denial #[Reference]
Patient: [Name, DOB, Member ID]

This letter provides medical justification for Ocrevus coverage:

DIAGNOSIS: Multiple sclerosis (G35), confirmed by [MRI findings, date]

PRIOR TREATMENTS: Patient has trialed and failed:
- [Drug name, dates, reason for discontinuation]
- [Drug name, dates, reason for discontinuation]

CURRENT STATUS: [Recent exam findings, progression evidence]

MEDICAL NECESSITY: Ocrevus is medically necessary due to:
- Documented failure of preferred alternatives
- FDA-approved indication for [relapsing/progressive] MS
- Patient's specific contraindications to other options

SAFETY SCREENING: Hepatitis B screening completed [date, result]

Sincerely,
[Physician name, NPI, contact]

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Step therapy not met Document specific trials, dates, and failure reasons for required drugs
Missing MS diagnosis Submit MRI reports and neurologist confirmation with ICD-10 G35
Inadequate prior authorization Resubmit with complete clinical documentation package
Not medically necessary Provide detailed medical necessity letter with guideline citations
Missing hepatitis B screening Submit recent HBV test results and vaccination records
Wrong benefit category Ensure submitted under Part B (not Part D) for infusions

Costs & Patient Assistance

Manufacturer Support:

Foundation Assistance:

  • National MS Society financial assistance programs
  • Patient Advocate Foundation copay relief
  • Good Days specialty drug assistance

State Resources:

  • North Carolina 211 for local assistance programs
  • Medicaid expansion (effective 2024) may provide additional coverage options

FAQ

How long does Humana prior authorization take for Ocrevus? Standard PA decisions typically take 5-14 business days. Expedited requests (when medically urgent) must be decided within 72 hours.

What if Ocrevus isn't on my Humana formulary? Request a formulary exception with medical necessity documentation. Humana must cover non-formulary drugs when medically necessary.

Can I get an expedited appeal in North Carolina? Yes, if your physician certifies that delays could seriously jeopardize your health. Both Humana and Smart NC (for commercial plans) offer expedited reviews.

Does step therapy apply if I failed other MS drugs outside North Carolina? Yes, document all prior therapy attempts regardless of where they occurred. Include medical records from previous providers.

What's the difference between Medicare Advantage and commercial plan appeals? Medicare Advantage follows federal CMS rules and cannot use Smart NC external review. Commercial plans have additional North Carolina state protections through Smart NC.

How much does Ocrevus cost without insurance? Specialty infusion biologics like Ocrevus can cost $65,000+ annually. Always explore manufacturer assistance programs and appeal denials rather than paying out-of-pocket.

Getting Help with Your Appeal

Counterforce Health specializes in turning 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 and drafts point-by-point appeals aligned with each payer's requirements, including the right medical evidence and procedural documentation that Humana expects for Ocrevus approvals.

For personalized assistance with your Humana appeal, consider working with experienced advocates who understand North Carolina's insurance landscape and can help navigate both internal appeals and external review options.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Humana directly and consult with your healthcare provider about treatment decisions. For official appeals guidance, contact Smart NC at 1-855-408-1212 or review your specific plan documents.

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