By Counterforce Health Team in Ocrevus (ocrelizumab) —

The Requirements Checklist to Get Ocrevus (ocrelizumab) Covered by Aetna (CVS Health) in Pennsylvania: Forms, Appeals, and Approval Timeline

Answer Box: Getting Ocrevus Covered by Aetna in Pennsylvania

Fastest path to approval: Submit Aetna's Ocrevus Medication Precertification Request form with neurologist documentation of MS diagnosis, prior therapy failures, and MRI evidence of disease activity. If denied, you can appeal internally within 180 days, then request Pennsylvania's Independent External Review within 4 months—which overturns ~50% of denials. Start today: Call Aetna member services (number on your ID card) to confirm your plan's prior authorization requirements and formulary status.

Table of Contents

Who Should Use This Guide

This checklist is designed for Pennsylvania residents with Aetna (CVS Health) insurance who need Ocrevus (ocrelizumab) for multiple sclerosis. Use this if you're:

  • Starting Ocrevus for the first time
  • Switching from another MS therapy
  • Facing a denial and need to appeal
  • A healthcare provider submitting prior authorization

Expected outcome: With complete documentation, initial approvals typically take 30-45 days. For denials, Pennsylvania's new external review process has a 50% success rate for overturning insurance decisions.

Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific rules.

Member & Plan Basics

Step 1: Verify Active Coverage

  • Check your Aetna ID card for current member ID and group number
  • Call member services (number on your card) to confirm:
    • Plan type (commercial, Medicare Advantage, Medicaid)
    • Specialty pharmacy requirements
    • Prior authorization needed for Ocrevus

Step 2: Understand Plan Requirements

Requirement Commercial Plans Medicare Plans Medicaid Plans
Prior Authorization Required Required Required
Neurologist Requirement Yes Yes Yes
Step Therapy Plan-specific Often required Plan-specific
Site of Care Restrictions May prefer non-hospital May prefer non-hospital Plan-specific
Note: Aetna Better Health Kids Pennsylvania lists Ocrevus with prior authorization and quantity limits as of December 2024.

Clinical Criteria Checklist

FDA-Approved Indications

Ocrevus must be prescribed for one of these conditions:

✅ Relapsing forms of MS:

  • Clinically isolated syndrome (CIS)
  • Relapsing-remitting MS (RRMS)
  • Active secondary progressive MS (SPMS)

✅ Primary progressive MS (PPMS)

Required Clinical Documentation

According to Aetna's Clinical Policy Bulletin #0264:

  • Age: 18 years or older
  • Prescriber: Neurologist or prescribed in consultation with neurologist
  • Single therapy: Not used with other disease-modifying MS therapies
  • Safety screening: HBV testing, vaccination status documented

Step Therapy Considerations

Some Aetna plans require trial/failure of preferred agents first:

Typical prerequisites:

  • Interferons (Avonex, Betaseron, Copaxone)
  • Oral agents (Tecfidera, Gilenya)

Failure documentation needed:

  • Inadequate response (continued relapses, new MRI lesions)
  • Intolerance to side effects
  • Medical contraindications

Required Documentation

Medical Necessity Letter Components

Your neurologist's letter should include:

  1. Patient identification: Name, DOB, Aetna member ID
  2. MS diagnosis: Specific type with ICD-10 code
  3. Disease activity evidence:
    • Recent MRI findings (new/enlarging T2 lesions, gadolinium enhancement)
    • Clinical relapses in past 12-24 months
    • Current EDSS score and progression
  4. Prior therapy history: Medications tried, duration, reason for discontinuation
  5. Safety screening: HBV results, vaccination status
  6. Treatment rationale: Why Ocrevus is medically necessary

Supporting Documents Checklist

  • Recent brain/spine MRI reports (within 12 months)
  • Neurology clinic notes with EDSS documentation
  • Prior therapy medication list with dates and outcomes
  • Laboratory results (HBV screening, CBC, liver function)
  • Insurance denial letter (if appealing)

Submission Process

Step 1: Complete the Correct Form

Download Aetna's Ocrevus Medication Precertification Request form.

Key sections to complete:

  • Member/insurance information
  • Prescriber details and specialty
  • MS type specification
  • Site of administration preference
  • Concomitant therapy attestation

Step 2: Submit Documentation

Timeline: Submit at least 2 weeks before planned infusion

Submission methods:

  • Fax: 1-888-267-3277 (preferred for Ocrevus precert)
  • Online: Availity provider portal with NovoLogix
  • Mail: Address on precertification form

Step 3: Specialty Pharmacy Coordination

If approved, Aetna may require use of:

  • CVS Specialty Pharmacy for drug supply
  • Approved infusion centers for administration

To verify network status: Call the Aetna number on your ID card and ask specifically about CVS Specialty and Coram infusion services availability in Pennsylvania.

After Submission: What to Expect

Timeline for Decisions

  • Standard review: 30-45 days
  • Expedited review: 72 hours (if urgent medical need)
  • Confirmation: You'll receive written determination

Status Tracking

  • Reference number: Keep your submission confirmation number
  • Follow up: Call Aetna after 2 weeks if no response
  • Provider portal: Check status via Availity if submitted online

Appeals Process in Pennsylvania

Internal Appeals (Required First Step)

If denied, you have 180 days to appeal internally with Aetna:

  1. Submit appeal via member portal or mail
  2. Include additional evidence (peer-reviewed studies, guidelines)
  3. Request peer-to-peer review with Aetna medical director
  4. Timeline: 30 days for standard, 72 hours for expedited

Pennsylvania Independent External Review

Pennsylvania launched a new state-run external review program in January 2024 with impressive results.

Key facts:

  • Success rate: 50% of appeals overturned in first year (259 out of 517 cases)
  • Deadline: 4 months after Final Adverse Benefit Determination
  • Cost: Free to consumers
  • Timeline: 45 days standard, 72 hours expedited

How to file:

  1. Complete internal appeals first
  2. Submit request at pa.gov/reviewmyclaim
  3. Include supporting documentation within 15 days of assignment
  4. Receive binding decision from independent medical reviewers
From our advocates: We've seen cases where patients initially denied for "experimental" treatment received approval after external review when the appeal included FDA labeling excerpts and peer-reviewed efficacy studies. The key was demonstrating that Ocrevus met standard-of-care guidelines for the patient's specific MS phenotype.

When to Contact Pennsylvania Insurance Department

For help with the process, contact:

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Provide clinical evidence of disease activity Recent MRI, relapse history, EDSS progression
"Step therapy not completed" Document prior therapy failures Medication list with dates, side effects, efficacy outcomes
"Experimental/investigational" Cite FDA approval and guidelines FDA labeling, AAN/ECTRIMS guidelines
"Site of care not appropriate" Justify hospital outpatient setting Document adverse reactions, venous access issues, medical instability
"Prescriber not qualified" Ensure neurologist involvement Neurologist attestation or consultation note

Cost Support Options

Manufacturer Support

  • Genentech Patient Foundation: Provides financial assistance for eligible patients
  • Ocrevus Connect: Copay assistance program (up to $20,000/year for commercial insurance)
  • Website: Gene.com/patients (verify current programs)

State and Foundation Programs

  • Pennsylvania CHIP: For children under 19
  • Patient Advocate Foundation: Copay relief programs
  • National MS Society: Financial assistance programs

FAQ

Q: How long does Aetna prior authorization take in Pennsylvania? A: Standard decisions take 30-45 days. Expedited reviews (for urgent medical needs) are completed within 72 hours.

Q: What if Ocrevus is non-formulary on my plan? A: You can request a formulary exception with medical necessity documentation. If denied, appeal through Pennsylvania's external review process.

Q: Can I use CVS Specialty with my Aetna plan? A: Many Aetna plans work with CVS Specialty, but verify network status by calling member services. CVS/Coram can often help with benefits investigation and prior authorization support.

Q: What counts as step therapy failure? A: Documented inadequate response (continued relapses, new MRI lesions), intolerance to side effects, or medical contraindications after appropriate trial period.

Q: Do I need to see a neurologist for Ocrevus approval? A: Yes. Aetna requires that Ocrevus be prescribed by a neurologist or in consultation with one. This must be documented on the precertification form.

Q: What if my appeal is denied in Pennsylvania? A: After exhausting Aetna's internal appeals, you can request Pennsylvania's Independent External Review within 4 months. This process has overturned 50% of denials in its first year.

Medical Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan for coverage determinations.

For personalized help with appeals and prior authorization, Counterforce Health specializes in turning insurance denials into evidence-backed appeals that meet each payer's specific requirements.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.