By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by Humana in Washington: Forms, Appeals, and Support Resources

Answer Box: Getting Ocrevus Covered by Humana in Washington

Ocrevus (ocrelizumab) requires prior authorization from Humana in Washington and may be subject to step therapy requirements. The fastest path to approval: (1) Have your neurologist submit a complete PA request through Humana's Availity portal with detailed MS diagnosis documentation and prior therapy failures, (2) coordinate specialty pharmacy fulfillment through CenterWell, and (3) verify your infusion site is in-network. If denied, you have 65 days to file an appeal and can request external review through MAXIMUS Federal Services for Medicare Advantage plans.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Online Resources
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Coordination
  6. Support Phone Lines and Case Management
  7. Washington State Appeals and External Review
  8. When to Update Your Resources

Verify Your Plan and Find the Right Forms

Before starting your Ocrevus (ocrelizumab) approval process, confirm your specific Humana plan type. Most Washington residents with Humana have Medicare Advantage plans, which follow different rules than commercial insurance.

Coverage at a Glance

Requirement What It Means Where to Find It Source
PA Required Yes, always required for Ocrevus Humana PA Search Tool Humana Provider Portal
Step Therapy May require trial of other MS drugs first Plan-specific formulary Humana Drug Lists
Specialty Pharmacy Must use approved network CenterWell coordination required CenterWell Specialty
Appeals Deadline 65 days from denial Medicare Advantage rules Medicare Appeals Guide

Prior Authorization Forms and Requirements

Current Forms (2024-2025)

For Ocrevus prior authorization with Humana, your healthcare provider must submit through the professionally administered drugs pathway since Ocrevus is given as an infusion.

Required Documentation:

  • Confirmed MS diagnosis with ICD-10 codes
  • MRI reports showing disease activity
  • Complete history of prior disease-modifying therapies (DMTs)
  • Documentation of treatment failures, intolerances, or contraindications
  • Current neurological assessment
  • Hepatitis B screening results
  • Vaccination status verification
Tip: The most current PA forms are available through the Humana Provider Portal. Forms are updated regularly, so always download the latest version.

Step Therapy Requirements

Humana may require you to try and fail other MS medications before approving Ocrevus. Common step therapy requirements include:

  • Injectable DMTs (interferons, glatiramer acetate)
  • Oral DMTs (fingolimod, dimethyl fumarate)
  • Documentation of at least 3-6 months on each therapy
  • Clear evidence of failure or intolerance

Submission Portals and Online Resources

Primary Submission Methods

Availity Provider Portal (Recommended)

  • Primary electronic submission system for Humana PAs
  • Fastest processing times
  • Real-time status tracking
  • Access at provider.humana.com

Humana Provider Portal

  • Direct access to PA forms and requirements
  • Drug lookup tools
  • Member eligibility verification
  • Login required for providers

Member Resources

MyHumana Member Portal

  • Track PA status
  • View coverage details
  • Access case management
  • Available at humana.com

Fax Numbers and Mailing Addresses

Key Contact Information

Prior Authorization Submissions:

  • Medicare PA Phone: 1-866-488-5995
  • General fax numbers available through provider portal (verify current numbers)

CenterWell Specialty Pharmacy:

  • Phone: 1-800-486-2668
  • Prescription fax: 1-877-405-7940
Note: Always verify fax numbers through the official Humana provider portal, as these can change. Include a cover sheet with member ID, provider NPI, and urgency level.

Specialty Pharmacy Coordination

Working with CenterWell

Ocrevus requires coordination through Humana's specialty pharmacy network. CenterWell Specialty Pharmacy manages most Humana specialty drug fulfillment.

Prescription Transfer Process:

  1. Provider e-prescribes to CenterWell or faxes to 1-877-405-7940
  2. CenterWell coordinates with your infusion site
  3. Drug is shipped directly to the approved facility
  4. Nursing support arranged if needed

Patient Support Services:

  • Financial assistance program navigation
  • Copay card coordination
  • Injection training (for self-administered formulations)
  • Adherence monitoring

Infusion Site Requirements

Your infusion must occur at a Humana in-network facility. Common options include:

  • Hospital outpatient infusion centers
  • Specialty neurology clinics
  • Approved home infusion services

Verify network status before scheduling through Humana's provider finder.

Support Phone Lines and Case Management

Member Services

Humana Customer Care: 1-800-281-6918 (TTY: 711)

  • General coverage questions
  • PA status inquiries
  • Appeals assistance
  • Case management requests

What to Ask When You Call:

  • "What's the status of my Ocrevus prior authorization?"
  • "Can you connect me with a case manager for specialty drugs?"
  • "What documentation is still needed for approval?"
  • "Can I request an expedited review?"

Provider Support

Availity Help Desk

  • Technical portal support
  • Submission troubleshooting
  • Available through provider portal

CenterWell Provider Line: 1-800-486-2668

  • Specialty pharmacy coordination
  • Prescription status
  • Site-of-care changes

Washington State Appeals and External Review

Important: Medicare Advantage vs. State Regulation

Critical distinction: If you have Humana Medicare Advantage, Washington state's insurance commissioner does not regulate your appeals process. Medicare Advantage appeals follow federal rules and go to federal contractors, not state agencies.

Federal Appeals Process for Medicare Advantage

Level 1: Plan Reconsideration

  • File within 60 days of denial
  • Submit through member portal or by phone
  • Decision within 7 days (standard) or 72 hours (expedited)

Level 2: Independent Review Entity (IRE)

  • Contact: MAXIMUS Federal Services
  • Phone: 1-866-763-6397
  • Fax: 1-585-425-5292

Address:

MAXIMUS Federal Services, Inc.
Medicare Managed Care Reconsideration Project
3750 Monroe Avenue, Suite 703
Pittsford, NY 14534-1302

Washington State Support Resources

While Washington's OIC can't handle Medicare Advantage appeals, they offer guidance:

SHIBA (Statewide Health Insurance Benefits Advisors)

  • Phone: 1-800-562-6900
  • Free, unbiased Medicare counseling
  • Help understanding federal appeals process
  • Available through Washington State OIC

When to Update Your Resources

Quarterly Check Points

January: New plan year changes, updated formularies April: Mid-year policy updates, new PA requirements
July: CMS regulation changes often effective October: Open enrollment preparation, next year's changes

Always verify:

  • Current PA form versions
  • Fax numbers and portal URLs
  • Step therapy requirements
  • Network provider status
  • Appeals deadlines and procedures

Red Flags to Re-Check Resources

  • Denial citing "outdated forms"
  • Portal login issues
  • Fax delivery failures
  • Changes in your provider's network status
  • New Ocrevus formulations (like Ocrevus Zunovo subcutaneous)

From Our Advocates

In our experience helping patients navigate Ocrevus approvals, the most successful cases include comprehensive documentation of prior therapy failures and clear neurological progression despite previous treatments. One common issue we see resolved is when patients provide vaccination records upfront—Humana often requires current immunizations before approving B-cell depleting therapies like Ocrevus, and proactive submission prevents delays.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies get prescription drugs approved by ingesting denial letters, plan policies, and clinical notes, then drafting point-by-point rebuttals aligned to each plan's specific requirements. For complex cases like Ocrevus approvals, we pull the right evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals that meet procedural requirements while tracking deadlines.

Frequently Asked Questions

How long does Humana prior authorization take for Ocrevus in Washington? Standard PA decisions are made within 7 calendar days. Expedited requests (for urgent medical situations) are decided within 72 hours. You can track status through the MyHumana portal or by calling customer service.

What if Ocrevus is not on Humana's formulary? You can request a formulary exception through Humana's exceptions and appeals process. Your doctor must provide medical justification for why formulary alternatives are not appropriate.

Can I get an expedited appeal in Washington? Yes, if your health could be seriously jeopardized by delays. Contact Humana customer service to request expedited processing, and have your doctor provide supporting documentation of medical urgency.

Does step therapy apply if I've tried other MS drugs outside Washington? Yes, prior therapy history from any location counts toward step therapy requirements. Ensure your new Washington provider has complete records of all previous treatments and outcomes.

What's the difference between Medicare Advantage and regular Medicare for Ocrevus coverage? Medicare Advantage plans like Humana have their own formularies and PA requirements. Original Medicare with Part B covers Ocrevus as a physician-administered drug, but you'd still need supplemental coverage for the significant coinsurance costs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and procedures change frequently. Always verify current requirements with Humana directly and consult with your healthcare provider about treatment decisions. For personalized assistance with appeals and coverage issues, consider contacting Counterforce Health or working with a patient advocate.

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