By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Humana in Ohio: Complete Forms, Appeals, and Coding Guide

Quick Answer: Getting Ocrevus Covered by Humana in Ohio

Ocrevus (ocrelizumab) requires prior authorization from Humana in Ohio. Your prescriber must submit clinical documentation proving medical necessity before coverage begins. If denied, you have two internal appeals with Humana, then up to 180 days to request an external review through the Ohio Department of Insurance.

First step today: Have your neurologist gather your MS diagnosis records, prior DMT trials, and complete Humana's prior authorization form via their provider portal or fax to 502-508-9300. Most approvals come within 7-30 days with complete documentation.

Table of Contents

  1. Coverage at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Coding That Gets Claims Paid
  4. Common Denial Reasons & Fixes
  5. Appeals Playbook for Humana in Ohio
  6. Costs & Patient Assistance
  7. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Humana plans in Ohio Provider portal or call 866-421-5663 Humana PA Lists
Formulary Status Preferred specialty drug for MS Member drug guide or MyHumana portal Humana Formulary
Medical Benefit Billed as J2350, not pharmacy benefit Claims processed under medical coverage Ocrevus Billing Guide
Step Therapy Not required - listed as preferred No prior DMT failures needed Humana PA Requirements
Appeal Deadline 180 days for external review in Ohio After final internal denial Ohio DOI Appeals

Step-by-Step: Fastest Path to Approval

1. Confirm Your MS Diagnosis Documentation

Who: Your neurologist
What: Complete MS workup with MRI findings, clinical symptoms, and specific MS subtype
Timeline: Before PA submission
Tip: Ensure diagnosis codes are specific (G35.A for relapsing-remitting MS, not just G35)

2. Submit Prior Authorization Request

Who: Prescribing physician or their staff
How: Humana provider portal or fax to 502-508-9300
Required: PA form, clinical notes, diagnosis confirmation, treatment rationale
Timeline: 7-30 days for standard review, 72 hours for expedited
Source: Humana Provider PA Process

3. Include Medical Necessity Documentation

Must have:

  • Confirmed MS diagnosis with subtype
  • Clinical rationale for Ocrevus over other DMTs
  • Baseline labs (CBC, liver function, hepatitis B screening)
  • Vaccination history and immunization plan

4. Track Your Request Status

Where: Humana provider portal or call 866-421-5663
Follow up: If no response in 14 days for standard requests
Document: Keep all correspondence and reference numbers

5. If Approved: Coordinate Infusion

Billing code: J2350 (1 mg = 1 unit)
Site: Infusion center or hospital outpatient
Scheduling: Initial doses 300mg (day 1), 300mg (day 15), then 600mg every 6 months

6. If Denied: Start Internal Appeal

Timeline: Must appeal within 60 days of denial
Submit to: Same PA department, marked "APPEAL"
Include: Additional clinical evidence, peer-reviewed studies, specialist letter

7. External Review if Needed

When: After exhausting internal appeals
Deadline: 180 days from final denial
Contact: Ohio Department of Insurance at 800-686-1526
Timeline: 30 days standard, 72 hours expedited

Coding That Gets Claims Paid

Medical vs. Pharmacy Benefit Path

Ocrevus is always billed under the medical benefit, never through the pharmacy. This means your infusion center or hospital submits claims using HCPCS J-codes, not NDC numbers to a pharmacy benefit manager.

HCPCS and Billing Units

Primary code: J2350 - "Injection, ocrelizumab, 1 mg"
Unit calculation: Each milligram = 1 billable unit

  • 300mg dose = 300 units
  • 600mg dose = 600 units

NDC for claims: 50242-0150-01 (300mg/10mL vial)
Modifier requirements:

  • JZ modifier if no drug wasted from single-use vial
  • JW modifier for any discarded amount (must bill separately)

Clean Request Anatomy

A complete prior authorization should include:

Patient Information:

  • Humana member ID and group number
  • Complete contact information
  • Primary care physician details

Clinical Documentation:

  • ICD-10 diagnosis code (G35.A, G35.B0, etc.)
  • Date of MS diagnosis and diagnostic criteria met
  • Current EDSS score or functional status
  • MRI findings supporting active disease

Treatment Rationale:

  • Why Ocrevus is medically necessary
  • Patient-specific factors favoring B-cell depletion
  • Contraindications to other DMTs if applicable
From Our Advocates: We've seen the strongest approvals when neurologists include a brief paragraph explaining why Ocrevus specifically fits the patient's disease pattern and lifestyle needs, rather than generic medical necessity language. Payers respond well to personalized clinical reasoning.

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
"Diagnosis not confirmed" Submit complete MS workup MRI reports, CSF analysis, McDonald criteria documentation
"Not medically necessary" Provide treatment-specific rationale Neurologist letter explaining why Ocrevus over alternatives
"Missing baseline labs" Complete safety screening CBC, CMP, hepatitis B surface antigen and antibody, quantiferon
"Inadequate vaccination history" Update immunizations Live vaccine completion ≥6 weeks before treatment
"Formulary restriction" Request formulary exception Clinical letter supporting non-formulary coverage

Most effective appeal strategy: Include peer-reviewed evidence supporting Ocrevus for your specific MS subtype and cite Humana's own medical policy criteria in your response.

Appeals Playbook for Humana in Ohio

Internal Appeals (Required First Step)

Level 1 Appeal:

  • Deadline: 60 days from denial notice
  • Submit to: Same PA department that issued denial
  • Method: Provider portal, fax, or mail
  • Timeline: 30 days for standard, 72 hours for urgent
  • Include: Additional clinical evidence, corrected information, specialist support letter

Level 2 Appeal (if Level 1 denied):

  • Deadline: 60 days from Level 1 denial
  • Process: Peer-to-peer review available
  • Decision: Final internal determination

External Review Through Ohio DOI

When internal appeals are exhausted:

  • Eligibility: Medical necessity denials, not contractual exclusions
  • Deadline: 180 days from final internal denial
  • Cost: Free to patients
  • Timeline: 30 days standard, 72 hours expedited
  • Decision: Binding on Humana if overturned

To request external review:

  1. Complete Ohio external review form
  2. Submit through Humana or directly to Ohio DOI
  3. Include all denial letters and medical records
  4. Call 800-686-1526 for assistance

Source: Ohio DOI External Review Process

Costs & Patient Assistance

Manufacturer Support Programs

Genentech Patient Foundation:

  • Copay assistance for eligible patients
  • Free drug program for uninsured/underinsured
  • Application through healthcare provider
  • Link: Genentech Access Solutions

Ohio-Specific Resources

Ohio Patient Advocate Foundation:

  • Copay relief for chronic disease medications
  • Case management for insurance appeals
  • Financial counseling services

Humana Coverage Gap Support:

  • Temporary coverage during appeals
  • Compassionate use programs
  • Financial hardship considerations

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create evidence-backed rebuttals. Their platform identifies the specific denial basis and drafts point-by-point responses aligned to each payer's own rules, helping patients get medications like Ocrevus approved faster.

FAQ

How long does Humana prior authorization take for Ocrevus in Ohio?
Standard requests: 7-30 days. Expedited requests (for urgent medical needs): 72 hours. Track status through the provider portal or by calling 866-421-5663.

What if Ocrevus isn't on my Humana formulary?
Request a formulary exception with your prior authorization. Include clinical documentation showing why Ocrevus is medically necessary over formulary alternatives.

Can I get an expedited appeal in Ohio?
Yes, if delay would seriously jeopardize your health. Your physician must certify urgency. Expedited internal appeals: 72 hours. Expedited external review: 72 hours.

Does step therapy apply if I haven't tried other MS drugs?
No. Ocrevus is listed as a preferred specialty drug for MS on Humana formularies, meaning step therapy requirements don't typically apply.

What happens if Ohio external review denies my appeal?
The external review decision is binding for administrative purposes, but you retain rights to other remedies including legal action or regulatory complaints to Ohio DOI.

How do I find my specific Humana plan's PA requirements?
Check your member portal, prescription drug guide, or call member services. PA requirements can vary between Humana Medicare Advantage, Medicaid, and commercial plans.

Can I start treatment while my appeal is pending?
Generally no, unless you pay out-of-pocket or qualify for manufacturer assistance. Some plans offer temporary coverage during expedited appeals for urgent situations.

What should I do if Humana claims my external review isn't eligible?
Contact the Ohio Department of Insurance at 800-686-1526. Ohio regulators can independently determine eligibility and order a review even if the insurer objects.

Disclaimer: This information is for educational purposes and doesn't constitute medical or legal advice. Coverage policies and procedures can change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions.

For assistance with insurance appeals and coverage decisions in Ohio, contact the Ohio Department of Insurance Consumer Services Division at 800-686-1526 or visit insurance.ohio.gov.

When traditional appeals aren't enough, Counterforce Health helps patients and clinicians build stronger cases by analyzing payer policies and crafting targeted, evidence-based appeals that address specific denial reasons with the right clinical documentation and regulatory citations.

Sources & Further Reading

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