By Counterforce Health Team in Ocrevus (ocrelizumab) —

How to Get Ocrevus (Ocrelizumab) Covered by UnitedHealthcare in Michigan: Prior Authorization Forms, Appeals, and Timeline Guide

Quick Answer: Ocrevus (ocrelizumab) requires prior authorization through UnitedHealthcare's OptumRx in Michigan. Start by confirming your MS diagnosis meets criteria (relapsing forms with failed first-line DMT, or PPMS under age 65 with EDSS ≤6.5), gather clinical documentation, and submit through your provider portal. If denied, you have 60 days for internal appeal and 127 days for Michigan DIFS external review. First step today: Contact your neurologist to request prior authorization and ensure proper ICD-10 coding (G35.A for RRMS, G35.B for PPMS).

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Coverage Basics
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in Michigan
  7. If You're Asked for More Information
  8. If Your Request Is Denied
  9. Renewal and Reauthorization
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This comprehensive guide helps Michigan patients and their healthcare providers navigate UnitedHealthcare's prior authorization process for Ocrevus (ocrelizumab), a disease-modifying therapy for multiple sclerosis. Whether you're newly diagnosed or switching treatments, understanding UnitedHealthcare's requirements can mean the difference between quick approval and months of delays.

Ocrevus is an anti-CD20 B-cell depleting therapy administered intravenously every six months (or subcutaneously with Ocrevus Zunovo). It's approved for relapsing forms of MS—including clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), and active secondary progressive MS—as well as primary progressive MS in adults.

Expected outcomes: With proper documentation, most Ocrevus prior authorization requests are approved within 7-14 days. Denials are typically related to incomplete clinical documentation or missing step therapy requirements, both of which can be addressed through appeals.

Before You Start: Coverage Basics

Verify Your Plan Type

UnitedHealthcare offers several plan types in Michigan, each with different prior authorization processes:

Medical vs. Pharmacy Benefit

Ocrevus is classified as a medical benefit medication under UnitedHealthcare plans, not a pharmacy benefit. This means it must be sourced through UnitedHealthcare-designated specialty pharmacies, typically Optum Specialty Pharmacy, and delivered via white-bagging to your infusion center.

Formulary Status

As of 2025, Ocrevus and Ocrevus Zunovo are designated as preferred agents for multiple sclerosis treatment under UnitedHealthcare plans.

Gather What You Need

Clinical Documentation Requirements

For Relapsing Forms of MS:

  • Confirmed MS diagnosis (RRMS, active SPMS, or CIS)
  • Documentation of inadequate response to at least one first-line DMT
  • Acceptable prior treatments include interferon beta-1a (Avonex), dimethyl fumarate, fingolimod, or glatiramer acetate

For Primary Progressive MS:

  • Patient under 65 years of age
  • EDSS score ≤6.5
  • Confirmed PPMS diagnosis

Updated ICD-10 Coding (Effective October 2025)

Important: Claims using the non-specific G35 code may be denied. Use these specific codes:
  • G35.A: Relapsing-remitting multiple sclerosis
  • G35.B1: Active primary progressive multiple sclerosis
  • G35.C1: Active secondary progressive multiple sclerosis

Required Documentation Checklist

  • Current MS diagnosis with appropriate ICD-10 code
  • EDSS score (required for PPMS and active SPMS)
  • Documentation of prior DMT trials and failures/intolerance
  • Recent MRI reports showing disease activity (if applicable)
  • Hepatitis B screening results
  • Current vaccination status
  • Complete medication list to rule out combination DMT use

Submit the Prior Authorization Request

Step-by-Step Submission Process

  1. Provider initiates request through UnitedHealthcare provider portal
  2. Include complete clinical documentation (see checklist above)
  3. Specify administration details: NDC/J-code (J2350), site of care, and administration plan
  4. Submit 3-4 weeks before scheduled infusion to allow processing time

Specialty Pharmacy Coordination

Your infusion center must coordinate with Optum Specialty Pharmacy for medication sourcing. Providers who don't obtain Ocrevus through designated specialty pharmacies will face payment denial.

Tip: Ask your infusion center to confirm their specialty pharmacy partnership before scheduling your first infusion.

Follow-Up and Tracking

When to Call UnitedHealthcare

  • Day 3-5: Confirm receipt of prior authorization request
  • Day 7-10: Check processing status if no response
  • Day 14: Request expedited review if still pending

Sample Phone Script

"I'm calling to check the status of a prior authorization request for Ocrevus (ocrelizumab) submitted on [date] for member [your name], ID number [policy number]. Can you provide the current status and any additional information needed?"

Document: Reference numbers, representative names, and next steps from each call.

Typical Timelines in Michigan

Standard Processing Times

  • Initial review: 7-14 calendar days for standard requests
  • Expedited review: 72 hours (available if health would be jeopardized by delay)
  • Additional information requests: Add 5-7 days to timeline

Michigan-Specific Protections

Michigan's Patient's Right to Independent Review Act provides additional consumer protections beyond federal requirements, including the 127-day window for external review requests.

If You're Asked for More Information

Common Information Requests

UnitedHealthcare may request additional documentation for:

  • Medical necessity justification: Detailed explanation of why Ocrevus is clinically appropriate
  • Prior therapy documentation: Complete records of previous DMT trials and outcomes
  • Disease progression evidence: Recent MRI or clinical assessment showing active disease

Responding Effectively

Submit requested information within the specified timeframe (typically 14 days) to avoid automatic denial. Include a cover letter summarizing how the additional documentation supports medical necessity.

If Your Request Is Denied

Understanding Denial Reasons

Common denial codes for Ocrevus include:

  • Insufficient documentation of prior DMT failure
  • Missing EDSS scores for PPMS patients
  • Incomplete hepatitis B screening
  • Use of non-specific ICD-10 codes

Internal Appeal Process

Timeline: 60 days from denial notice to file internal appeal

Required elements:

  • Completed appeal form
  • Original denial letter
  • Additional clinical documentation addressing denial reason
  • Provider attestation letter

Peer-to-Peer Review Option

Before formal appeals, request a peer-to-peer review where your neurologist speaks directly with a UnitedHealthcare medical director. This process takes 5-10 minutes to schedule and often resolves coverage issues quickly.

Michigan External Review Process

If UnitedHealthcare denies your internal appeal, you have 127 days to file an external review with Michigan's Department of Insurance and Financial Services (DIFS). Contact DIFS at 877-999-6442 or use their online External Review Request form.

Expedited external review: Available within 72 hours if your doctor certifies that delay would harm your health.

Renewal and Reauthorization

When to Start Renewal Process

Begin reauthorization 6-8 weeks before your current approval expires. UnitedHealthcare has eliminated reauthorization requirements for nearly 70 chronic disease drugs, but Ocrevus may still require periodic review.

Documentation for Renewal

  • Updated clinical assessment
  • Evidence of treatment response or disease stability
  • Current EDSS score
  • Any new safety monitoring results
Note: Patients already established on Ocrevus typically continue coverage without requiring new step therapy protocols.

Quick Reference Checklist

Before Starting:

  • Verify UnitedHealthcare plan type and specialty pharmacy requirements
  • Confirm infusion center partnerships with Optum Specialty Pharmacy
  • Gather complete clinical documentation

For Submission:

  • Use specific ICD-10 codes (G35.A, G35.B1, G35.C1)
  • Include EDSS scores for PPMS/active SPMS patients
  • Document prior DMT trials and outcomes
  • Submit 3-4 weeks before needed

If Denied:

  • Request peer-to-peer review first
  • File internal appeal within 60 days
  • Consider Michigan DIFS external review (127-day window)

Frequently Asked Questions

Q: How long does UnitedHealthcare prior authorization take in Michigan? A: Standard requests take 7-14 days; expedited requests are processed within 72 hours if clinical urgency is documented.

Q: What if Ocrevus is non-formulary on my plan? A: As of 2025, Ocrevus is designated as a preferred agent. If your specific plan differs, your provider can request a formulary exception with clinical justification.

Q: Can I request expedited review for Ocrevus? A: Yes, if your neurologist documents that delay would jeopardize your health, you can request expedited processing at both the initial review and appeal levels.

Q: Does step therapy apply if I've failed DMTs outside Michigan? A: Prior therapy failures from other states count toward UnitedHealthcare's step therapy requirements, provided you have documentation.

Q: What's the cost impact of the 2025 Medicare changes? A: UnitedHealthcare Medicare beneficiaries have a $2,000 annual out-of-pocket maximum for specialty medications like Ocrevus.

Q: Who can file an appeal on my behalf? A: Your physician or another authorized representative can file appeals with your written consent, which is often helpful given the clinical complexity involved.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform identifies denial basis and drafts point-by-point rebuttals aligned to each plan's specific rules, pulling the right citations and clinical facts to support coverage requests.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For assistance with Michigan insurance appeals, contact the Department of Insurance and Financial Services at 877-999-6442.

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