By Counterforce Health Team in Ocrevus (ocrelizumab) —

UnitedHealthcare's Coverage Criteria for Ocrevus in New Jersey: What Counts as "Medically Necessary"?

Answer Box: Getting Ocrevus Covered by UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization for Ocrevus (ocrelizumab) in New Jersey, with specific medical necessity criteria for both relapsing and primary progressive MS. The fastest path to approval: ensure you have a confirmed MS diagnosis, document any failed prior therapies, and submit through the UnitedHealthcare Provider Portal. If denied, New Jersey's IHCAP external review program offers a strong pathway to overturn decisions, with approximately 50% success rates for specialty drug appeals.

First step today: Contact your neurologist to verify your MS diagnosis documentation and gather records of any previous disease-modifying therapies you've tried.

Table of Contents

  1. Policy Overview
  2. Medical Necessity Requirements
  3. Step Therapy & Exception Pathways
  4. Required Documentation
  5. Site of Care Requirements
  6. Appeals Process in New Jersey
  7. Common Denial Reasons & Solutions
  8. Cost Support Options
  9. FAQ

Policy Overview

UnitedHealthcare covers Ocrevus (ocrelizumab) for multiple sclerosis under strict medical necessity criteria that apply across all plan types—HMO, PPO, and Medicaid plans in New Jersey. The drug requires prior authorization through OptumRx, UnitedHealthcare's specialty pharmacy benefit manager.

Coverage at a Glance

Requirement Details Documentation Needed Policy Reference
Prior Authorization Required for all plans Complete PA form via provider portal UHC Commercial PA Requirements
Diagnosis Confirmed relapsing MS or PPMS Medical records, MRI reports Ocrevus Medical Policy
Monotherapy No combination with other DMTs Current medication list Same as above
Step Therapy May apply for relapsing MS Prior therapy records Same as above
Authorization Period Up to 12 months initially Clinical response documentation Same as above

Medical Necessity Requirements

UnitedHealthcare's medical policy for Ocrevus defines medical necessity based on FDA-approved indications and specific clinical criteria.

For Relapsing Forms of MS

Your doctor must document:

  • Confirmed diagnosis of relapsing-remitting MS, secondary progressive MS with relapses, or clinically isolated syndrome
  • Monotherapy requirement: Ocrevus cannot be used with other disease-modifying therapies or B-cell targeted treatments
  • FDA-compliant dosing: Initial dose of 300 mg IV, followed by 300 mg two weeks later, then 600 mg every six months

For Primary Progressive MS (PPMS)

The criteria are similar but specifically require:

  • Documented PPMS diagnosis with evidence of disability progression
  • Age and disability considerations: Most coverage aligns with FDA trial data (adults under 55 with EDSS ≤6.5)
  • MRI evidence: Active lesions or progression markers support approval
Clinician Corner: When writing medical necessity letters, reference the FDA prescribing information and include specific EDSS scores, relapse frequency, and MRI findings. The stronger your clinical documentation, the more likely approval becomes.

Step Therapy & Exception Pathways

UnitedHealthcare may require patients with relapsing MS to try other disease-modifying therapies first, but New Jersey's new step therapy protections offer significant patient safeguards.

Standard Step Therapy Requirements

For relapsing MS, UnitedHealthcare typically requires trials of:

  1. Injectable therapies (interferons, glatiramer acetate)
  2. Oral first-line options (dimethyl fumarate, teriflunomide)
  3. Higher-efficacy options may be considered based on disease activity

New Jersey Step Therapy Protections (2026)

Starting January 1, 2026, Assembly Bill A1825 enhances protections for specialty drugs like Ocrevus:

  • 24-72 hour exception approval when step therapy drugs are contraindicated
  • Clinical stability protection: If you're stable on Ocrevus, UnitedHealthcare cannot force a switch
  • Expedited appeals for step therapy denials

Medical Exception Documentation

To bypass step therapy, your neurologist should document:

  • Contraindications to preferred therapies (allergies, drug interactions)
  • Previous failures with specific details about inadequate response or intolerance
  • Disease severity requiring immediate high-efficacy treatment

Required Documentation

Success with UnitedHealthcare prior authorization depends on comprehensive clinical documentation submitted through the provider portal.

Essential Clinical Records

Diagnostic Documentation:

  • MRI reports showing lesions consistent with MS
  • Cerebrospinal fluid analysis (if performed)
  • Neurological examination findings
  • EDSS or other disability scores

Treatment History:

  • Complete list of previous MS therapies
  • Dates of treatment, duration, and outcomes
  • Reasons for discontinuation (inefficacy, intolerance, contraindications)
  • Current medication list

Disease Activity Evidence:

  • Recent relapse history (dates, symptoms, recovery)
  • MRI progression (new lesions, gadolinium enhancement)
  • Disability progression measures

Sample Medical Necessity Narrative

"Patient has relapsing-remitting multiple sclerosis diagnosed in [year] with MRI evidence of dissemination in time and space. Despite trials of [specific therapies] over [timeframe], patient experienced [specific outcomes: continued relapses, MRI progression, intolerance]. Current EDSS score of [X] and recent MRI showing [findings] demonstrate ongoing disease activity requiring high-efficacy therapy. Ocrevus is medically necessary as an FDA-approved B-cell depleting therapy with demonstrated efficacy in reducing relapse rates and disability progression in RRMS."

Site of Care Requirements

UnitedHealthcare actively manages where Ocrevus infusions can be administered to control costs while ensuring patient safety.

Preferred Infusion Sites

  1. Outpatient infusion centers (lowest cost-sharing)
  2. Neurologist offices with infusion capabilities
  3. Home infusion (where medically appropriate)

Hospital Outpatient Departments

UnitedHealthcare may require additional authorization for hospital-based infusions unless:

  • Patient has complex comorbidities requiring hospital-level monitoring
  • No alternative infusion sites available in reasonable proximity
  • Medical necessity documented for hospital setting

OptumRx Specialty Pharmacy

Ocrevus must be sourced through UnitedHealthcare's specialty pharmacy network. Your infusion center will coordinate with OptumRx for drug procurement and delivery.

Tip: Verify your infusion site's network status before scheduling. Out-of-network facilities may result in higher patient costs or claim denials.

Appeals Process in New Jersey

New Jersey offers one of the strongest patient protection systems in the country for insurance appeals, managed by Maximus Federal Services through the Independent Health Care Appeals Program (IHCAP).

Internal Appeals with UnitedHealthcare

First Level Internal Appeal:

  • Submit within 180 days of denial
  • Use UnitedHealthcare Provider Portal for electronic submission
  • Include additional clinical documentation
  • Decision within 30 days (15 days for urgent cases)

Second Level Internal Appeal:

  • Required before external review
  • Same submission process and timelines
  • Independent medical reviewer (not involved in original decision)

New Jersey External Review (IHCAP)

After exhausting internal appeals, New Jersey residents can access external review through IHCAP:

Eligibility:

  • Fully-insured commercial UnitedHealthcare plans regulated by New Jersey
  • Medical necessity denials only
  • Must complete internal appeals first

Success Rates:

  • Approximately 50% of external appeals are overturned nationwide
  • Higher success rates for specialty drugs like Ocrevus
  • Independent physician reviewers with MS expertise

How to File:

  1. Submit application within 4 months of final internal denial
  2. Use Maximus portal or mail/fax
  3. Include all medical records and denial letters
  4. No cost to patient—UnitedHealthcare pays all review fees

Timeline:

  • Preliminary review: 5 business days
  • Final decision: 45 days (expedited available for urgent cases)
  • Decision is binding on UnitedHealthcare
From Our Advocates: We've seen several New Jersey patients successfully overturn Ocrevus denials through IHCAP, particularly when neurologists provided detailed letters explaining why step therapy options were inappropriate due to disease severity or previous treatment failures. The key is comprehensive documentation of medical necessity.

For IHCAP questions, call the dedicated hotline at 1-888-393-1062 or the general NJ Department of Banking & Insurance consumer line at 1-800-446-7467.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not FDA-approved indication" Verify MS diagnosis in medical records MRI reports, neurologist consultation notes, diagnostic criteria
"Step therapy not completed" Document contraindications or failures Prior therapy records, adverse event reports, medical exception request
"Combination therapy prohibited" Confirm monotherapy use Current medication list, pharmacy records
"Insufficient clinical documentation" Submit comprehensive medical records Complete treatment history, MRI progression, disability scores
"Not medically necessary" Provide evidence-based rationale Peer-reviewed studies, clinical guidelines, patient-specific factors

Cost Support Options

Even with UnitedHealthcare coverage, Ocrevus can involve significant out-of-pocket costs. Several support programs can help:

Genentech Patient Foundation

  • Ocrevus Co-pay Program: Eligible patients may pay as little as $5 per infusion
  • Eligibility: Commercial insurance, income requirements
  • Apply: Ocrevus.com patient support

State and Federal Programs

  • New Jersey Pharmaceutical Assistance: For Medicare beneficiaries
  • Medicare Extra Help: Low-income subsidy program
  • Medicaid: May cover Ocrevus with prior authorization

Foundation Grants

Multiple MS-focused foundations offer medication assistance grants. Your neurologist's office or Counterforce Health can help identify relevant programs.

FAQ

How long does UnitedHealthcare prior authorization take in New Jersey? Standard prior authorizations are processed within 15 business days. Urgent requests (when delay could harm your health) are processed within 72 hours.

What if Ocrevus is non-formulary on my plan? Non-formulary drugs can still be covered with prior authorization demonstrating medical necessity. The process is the same, but may require stronger clinical justification.

Can I request an expedited appeal? Yes, if delaying treatment could seriously harm your health. Your doctor must document the urgency in the appeal request.

Does step therapy apply if I've been on Ocrevus before? Generally no. If you were stable on Ocrevus and switch to a new UnitedHealthcare plan, step therapy typically doesn't apply due to clinical stability protections.

What happens if my appeal is denied? After internal appeals, you can file for external review through New Jersey's IHCAP program. This independent review has approximately 50% success rates for specialty drug appeals.

How much will Ocrevus cost with UnitedHealthcare? Costs vary by plan design. Typical ranges include $50-500 per infusion for commercial plans, with higher costs for high-deductible plans until the deductible is met.

Sources & Further Reading

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements. For complex cases involving UnitedHealthcare and Ocrevus, Counterforce Health can help identify the exact denial basis and craft appeals that address payer-specific criteria while incorporating the right clinical evidence and procedural requirements.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan, and policies change frequently. Always consult your healthcare provider for medical decisions and verify current coverage requirements with UnitedHealthcare directly. For personalized assistance with New Jersey insurance appeals, contact the NJ Department of Banking & Insurance at 1-800-446-7467.

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