By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by UnitedHealthcare in California: Renewal Guide, Appeal Scripts, and Timeline

Answer Box: Getting Ocrevus Covered by UnitedHealthcare in California

UnitedHealthcare requires prior authorization for Ocrevus (ocrelizumab) with annual renewal documentation showing clinical response. Submit via the UHC Provider Portal with MS diagnosis confirmation, prior DMT trials, and evidence of treatment benefit (stable/improved disability scores, reduced relapses, or MRI stability). If denied, California residents can file an Independent Medical Review (IMR) through DMHC with a ~73% success rate. Start today: Check your formulary tier at myuhc.com and gather your latest MRI report and clinic notes.

Table of Contents

  1. Renewal Triggers: When to Start Early
  2. Evidence Update: What UnitedHealthcare Wants to See
  3. Renewal Packet: Must-Include Documents
  4. Timeline: Submission Windows and Decision Periods
  5. If Coverage Lapses: Bridge Options and Escalation
  6. Annual Changes: Formulary Moves and Plan Updates
  7. Appeals Playbook for California
  8. Personal Tracker Template
  9. FAQ: Common Questions

Renewal Triggers: When to Start Early

UnitedHealthcare's OptumRx requires annual prior authorization renewal for Ocrevus, with no elimination of reauthorization requirements as of 2025 (unlike some chronic medications). Start your renewal process 60-90 days before your current authorization expires to avoid treatment gaps.

Key Timing Windows

Scenario When to Submit Why
Stable on therapy 60 days before expiration Standard processing takes 15-30 days
Recent MRI changes 90 days before expiration May need peer-to-peer review
New symptoms/relapses Immediately Requires updated clinical assessment
Plan change (job/marriage) Before effective date New plan = new authorization

Early warning signs to expedite renewal:

  • New neurological symptoms lasting >24 hours
  • Missed or delayed infusions due to scheduling
  • Recent hospitalizations or infections
  • Changes in disability scores (EDSS)
  • Plan notifications about formulary changes

Evidence Update: What UnitedHealthcare Wants to See

UnitedHealthcare's medical policy for ocrelizumab requires documentation of positive clinical response for renewal. Here's what counts as evidence:

Clinical Response Documentation

Strong Evidence (any one sufficient):

  • Relapse reduction: Fewer relapses compared to pre-treatment period
  • MRI stability: No new gadolinium-enhancing lesions or <2 new T2 lesions annually
  • Disability stabilization: Stable or improved EDSS scores over 6-12 months
  • Functional improvement: Better performance on timed 25-foot walk or 9-hole peg test

Supporting Evidence:

  • Adherence to 6-month infusion schedule
  • Appropriate monitoring (B-cell counts, immunoglobulin levels)
  • No serious infections or safety concerns
  • Patient-reported quality of life improvements
From our advocates: We've seen renewals approved faster when clinicians include a one-paragraph summary comparing the patient's current status to their baseline before starting Ocrevus. Specific metrics like "reduced from 3 relapses/year to 0 relapses in past 18 months" carry more weight than general statements about "doing well."

What Triggers Closer Review

  • New MRI activity: >2 new T2 lesions or any gadolinium-enhancing lesions
  • Breakthrough relapses: Confirmed relapses while on therapy
  • Serious infections: Requiring hospitalization or IV antibiotics
  • Low immunoglobulin levels: Below normal range without clear cause

Renewal Packet: Must-Include Documents

Core Requirements Checklist

✅ Prior authorization form (submit via UHC Provider Portal) ✅ Updated clinic note (within 90 days) documenting:

  • Current MS phenotype (RRMS, PPMS, active SPMS)
  • Treatment response summary
  • Current EDSS or functional status
  • Any adverse events or infections

✅ Recent MRI report (brain ± spine, within 12 months) ✅ Infusion records showing adherence to 6-month schedule ✅ Laboratory results (if monitoring required):

  • Complete blood count
  • Immunoglobulin levels (if tracked)
  • Hepatitis B screening (if initial concern)

Medical Necessity Letter Structure

Your neurologist's letter should address these points in order:

  1. Patient identification: Age, MS duration, phenotype
  2. Treatment history: Prior DMTs tried, reasons for discontinuation
  3. Ocrevus response: Specific metrics (relapses, MRI, EDSS)
  4. Current status: Functional assessment, quality of life
  5. Medical necessity: Why continuation is essential
  6. Alternative assessment: Why other DMTs are less suitable

Sample language: "Ms. [Patient] has relapsing-remitting MS diagnosed in [year]. Prior to Ocrevus, she experienced [X] relapses annually despite trials of [list DMTs and outcomes]. Since initiating Ocrevus in [date], she has had [X] relapses and MRI shows [specific findings]. Her EDSS has [improved/stabilized] from [X] to [X]. Discontinuation would place her at significant risk of disease reactivation."

Timeline: Submission Windows and Decision Periods

Standard Processing Timeline

Step Timeframe Action Required
Submit PA 60 days before expiration Provider submits via portal/fax
Initial review 5-15 business days UHC reviews documentation
Decision issued 15-30 business days total Approval, denial, or more info request
Appeals (if needed) Within 180 days of denial Internal appeal submission

Expedited Processing

For urgent situations (treatment interruption would cause immediate harm):

  • Submit expedited PA with clinical urgency justification
  • Decision timeline: 72 hours for urgent determinations
  • Required documentation: Letter explaining why delay would be harmful

Contact for urgent submissions:

  • Commercial plans: 888-397-8129
  • OptumRx pharmacy: 1-800-711-4555

If Coverage Lapses: Bridge Options and Escalation

Immediate Actions (First 30 Days)

  1. Contact Ocrevus Connects: 1-844-627-3687
    • Request temporary supply or bridge program
    • Apply for copay assistance (up to $25,000/year for eligible patients)
    • Explore patient assistance programs for uninsured/underinsured
  2. File urgent appeal with UnitedHealthcare
    • Request expedited review citing treatment interruption risk
    • Submit via member portal or call customer service
  3. Bridge therapy consideration (consult neurologist):
    • Not typically needed due to Ocrevus's 6-month dosing and sustained B-cell depletion
    • Consider only if high disease activity or >3 month gap expected

Extended Gaps (>30 Days)

Financial assistance options:

  • Genentech Access Solutions: Income-based assistance programs
  • State pharmaceutical assistance: California's programs for residents
  • Nonprofit foundations: National MS Society, Patient Access Network

Clinical monitoring during gaps:

  • Monthly symptom checks
  • MRI if new symptoms develop
  • B-cell count monitoring (recovery typically takes 6-9 months)

When Counterforce Health works with patients facing coverage gaps, we help coordinate between the manufacturer's patient assistance programs and the appeals process to minimize treatment interruption. Our platform can quickly generate the clinical documentation needed for urgent appeals while simultaneously preparing comprehensive evidence packages for external review.

Annual Changes: Formulary Moves and Plan Updates

What to Verify Each January

Check your plan's 2025 formulary status:

  • Tier placement: Specialty tier vs. higher cost-sharing tiers
  • Prior authorization requirements: New step therapy rules
  • Quantity limits: Infusion frequency restrictions
  • Site of care requirements: Infusion center vs. home administration

Where to check:

  • UnitedHealthcare member portal (myuhc.com)
  • OptumRx formulary search
  • Plan's Summary of Benefits and Coverage (SBC)

Common 2024-2025 Changes

Based on UnitedHealthcare's formulary updates, monitor for:

  • Tier increases: Higher copays/coinsurance
  • New step therapy: Required trial of lower-cost DMTs first
  • Prior authorization additions: Plans adding PA requirements
Note: UnitedHealthcare's 2025 Medicare Part D changes specifically mention MS drug modifications, with some interferons becoming non-formulary. Ocrevus remains covered but verify your specific plan details.

Appeals Playbook for California

California offers robust appeal rights through two regulatory agencies. Most UnitedHealthcare plans fall under DMHC (Department of Managed Health Care) oversight.

Level 1: Internal Grievance with UnitedHealthcare

Timeline: Must file within 180 days of denial Process:

  1. Submit via UHC member portal or mail grievance form
  2. Include all supporting documentation
  3. UHC has 30 days to respond (3 days for urgent)

Required documents:

  • Denial letter
  • Medical records supporting necessity
  • Physician letter of support

Level 2: California Independent Medical Review (IMR)

Eligibility: After internal grievance is denied or 30 days pass without response Timeline: File within 6 months of final internal denial Success rate: ~73% of IMRs rule in favor of patients (DMHC data)

How to file:

  1. Online: www.dmhc.ca.gov (fastest method)
  2. Phone: 1-888-466-2219 (24/7 for urgent cases)
  3. Mail: Include IMR application and all medical records

IMR timeline:

  • Routine cases: Decision within 45 days
  • Expedited cases: Decision within 7 days (often 72 hours)

When UnitedHealthcare Must Comply

Binding decisions: If IMR approves your request, UnitedHealthcare must:

  • Authorize the treatment within 5 business days
  • Pay for services retroactively if already received
  • Cannot appeal the IMR decision

Personal Tracker Template

Renewal Checklist

Current Authorization Details:

  • Authorization number: ________________
  • Expiration date: ________________
  • Approved dose/frequency: ________________
  • Next renewal due: ________________

Documentation Status:

  • Recent clinic note (within 90 days)
  • Latest MRI report (within 12 months)
  • Infusion records updated
  • Lab results (if required)
  • Medical necessity letter prepared

Submission Tracking:

  • Date submitted: ________________
  • Confirmation number: ________________
  • Expected decision date: ________________
  • Decision received: ________________
  • Next action needed: ________________

FAQ: Common Questions

How long does UnitedHealthcare prior authorization take for Ocrevus in California? Standard processing is 15-30 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Ocrevus becomes non-formulary on my plan? You can request a formulary exception with clinical documentation. If denied, file an IMR through DMHC for external review.

Does step therapy apply if I've already been stable on Ocrevus? Continuation therapy typically bypasses step therapy requirements. Document your positive response to treatment in the renewal application.

Can I request an expedited appeal in California? Yes, both UnitedHealthcare internal appeals and DMHC IMRs offer expedited processing for urgent medical situations.

What counts as "positive clinical response" for renewal? Reduced relapses, MRI stability (no new enhancing lesions), stable/improved EDSS scores, or improved functional measures compared to pre-treatment baseline.

How much does an IMR cost in California? IMRs are free to patients. The health plan pays all review costs, including independent physician expert fees.

What if my doctor doesn't want to write a medical necessity letter? Provide them with UnitedHealthcare's specific clinical criteria and offer to draft key points. Most neurologists will collaborate on renewal documentation when given clear guidance.

Can I continue Ocrevus if I move from California to another state? Your UnitedHealthcare coverage travels with you, but check if your specific plan is available in your new state and verify formulary coverage.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that meet payer-specific requirements and procedural deadlines.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance.

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