CurrentCareSourcePolicy N/A

Multiple Sclerosis Ocrevus Utilization Management Medical Policy

Defines prior authorization, coverage criteria, dosing, and limitations for Ocrevus (ocrelizumab) for adults with relapsing forms of MS and primary progressive MS; applies to providers prescribing Ocrevus under CareSource.

Policy Summary

PayerCareSource

PolicyMultiple Sclerosis Ocrevus Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeCoverage criteria updatedappendix expanded

Effective DateN/A

Next Review DateOct 9, 2024

Key ActionRequest prior authorization and ensure Ocrevus is prescribed by or in consultation with a neurologist or MS specialist.

SourceLink

POLICY UPDATE CHANGES

Ocrevus Zunovo was added to the Appendix.

Manufacturer name updated to Genentech/Roche in prescribing information references.

Requirement that the patient must have had inadequate efficacy or intolerance to one prior disease-modifying agent for initial relapsing MS criteria was removed.

2FDA indications

1 yearApproval duration

300/600 mgDosing regimens

Not recommendedConcurrent DMTs

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

FDA-Approved Indications (Relapsing Forms and Primary Progressive)

Covered when ALL of the following are met for each indication

Relapsing Forms - General: Patient is >= 18 years of age; patient has a relapsing form of multiple sclerosis (examples include clinically isolated syndrome, relapsing remitting disease, or active secondary progressive MS); medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.

Relapsing Forms - Initial or Continuation: Initial Therapy: approve for 1 year if patient meets ALL of the initial therapy specifics; Continuation/1‑Year Approval: approve for 1 year if patient meets ALL continuation specifics (including evidence of clinical benefit or stabilization).

Clinical Response Evidence: Patient experienced a beneficial clinical response as assessed by at least one objective measure (e.g., MRI activity reduction such as absence/decrease in gadolinium‑enhancing lesions or fewer new/enlarging T2 lesions; stabilization or reduced worsening on EDSS; achievement of NEDA‑3 or NEDA‑4; reduction in relapse rate; improvement on functional measures such as 6‑minute walk, 12‑Item MS Walking Scale, MSFC; attenuation of brain volume loss) OR patient experienced stabilization, slowed progression, or improvement in at least one symptom (motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, pain, numbness/tingling).

Primary Progressive MS: Patient is >= 18 years of age AND Ocrevus is prescribed by or in consultation with a physician who specializes in the treatment of multiple sclerosis and/or a neurologist.

Dosing Options: Either 300 mg IV followed 2 weeks later by a second 300 mg IV OR 600 mg IV once every 6 months.

Requests for coverage when Ocrevus (ocrelizumab) is being used concurrently with other disease‑modifying therapies (DMTs) for multiple sclerosis are not recommended. The policy notes that these agents are generally not indicated for combination use and that additional data are required to demonstrate safety and added efficacy; the Appendix provides examples of other DMTs (e.g., Briumvi, Kesimpta, Lemtrada, Gilenya, and many oral and injectable agents) to guide operational review.

When submitting authorization requests, include documentation that Ocrevus will be used as a single DMT (not in combination). If concurrent therapy is proposed, provide clinical rationale and supporting evidence demonstrating safety and benefit for the specific combination; absent such data requests may be denied consistent with the policy.

Coverage of Ocrevus is not recommended for circumstances that are not explicitly listed in the Recommended Authorization Criteria. The policy states that criteria will be updated as new published data become available, and requests falling outside the stated criteria should not be expected to meet coverage without additional supporting evidence.

Use of Ocrevus in combination with other multiple sclerosis disease‑modifying therapies is considered not medically necessary unless there is clear supporting data demonstrating safety and added benefit. Operationally, requests that propose combination DMT therapy should include a specific, evidence‑based rationale and relevant clinical data; absent that supporting information, the request is subject to non‑coverage or denial per the policy.

Prior Authorization, Prescriber Requirements, and Utilization Controls

Prior Authorization

Prior Authorization Required

Prior Authorization is required for medical benefit coverage of Ocrevus. Approval is granted only when the patient meets the listed Criteria and Dosing for the indicated condition. All approvals are provided for the duration noted in the policy and requests for doses outside the established dosing will be reviewed case-by-case by a clinician (Medical Director or Pharmacist).

Prior authorization applies to Ocrevus medical benefit claims
Requests for non-standard dosing considered case-by-case by clinician review

Step Therapy

Step Therapy Change

Step therapy requirement removed: the prior criterion requiring failure of another disease-modifying therapy (DMT) before starting Ocrevus for relapsing forms of multiple sclerosis has been deleted. Ocrevus may be considered without first documenting inadequate efficacy or intolerance to another DMT when the other coverage criteria are met.

Updated: No prerequisite DMT failure required for relapsing MS initial approval

Note

Prescriber and Approval Duration

Prescriber specialty requirement and approval duration: Ocrevus must be prescribed by, or in consultation with, a physician who specializes in the condition being treated (e.g., a neurologist for multiple sclerosis). Approvals are typically issued for the duration specified in the policy (for example, 1 year for FDA‑approved MS indications) and may be extended if the patient continues to meet criteria.

Prescriber: physician who specializes in the condition treated (e.g., neurologist for MS)
Standard approval duration: 1 year for FDA‑approved MS indications; extensions allowed if criteria continue to be met

Denial Risk

Concurrent DMT Use — Not Recommended

Concurrent use of Ocrevus with other disease-modifying therapies (DMTs) for multiple sclerosis is not recommended and is a basis for non‑coverage. These agents are not indicated for combination use; additional data are required to establish safety and additive efficacy.

Requests for concurrent DMT use (e.g., Ocrevus plus another MS DMT) are typically denied/not recommended
See Appendix for examples of other DMTs (updates include newly listed agents such as Briumvi and Ocrevus Zunovo noted in revisions)

Clinical Background

Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating autoimmune disease of the central nervous system that most commonly presents in adults between approximately 20–40 years of age and follows relapsing and/or progressive clinical courses. Clinical phenotypes referenced in the policy include clinically isolated syndrome, relapsing‑remitting MS, active secondary progressive MS, and primary progressive MS.

Ocrevus (ocrelizumab) is a CD20‑directed therapy indicated for both relapsing forms of MS and primary progressive MS; the policy frames coverage and authorization criteria around these FDA‑approved indications, age thresholds (≥18 years), prescriber requirements, and documented clinical benefit for continuation treatment.

OpenPayer

Multiple Sclerosis Ocrevus Utilization Management Medical Policy

Coverage and Medical Necessity Criteria

Product Codes, Age, and Related Coding Details

Prior Authorization, Prescriber Requirements, and Utilization Controls

Clinical Background

Definitions and Terminology