CurrentCignaPolicy N/A

Ocrevus (ocrelizumab) prior authorization and coverage form

This document governs prior authorization submission requirements and clinical information collection for requests to obtain ocrelizumab (Ocrevus) for Cigna members, affecting prescribers, infusion sites, specialty pharmacy, and billing providers.

Policy Summary

PayerCigna

PolicyOcrevus (ocrelizumab) prior authorization and coverage form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the prior authorization form with required patient/provider fields and documentation of diagnosis, prescriber specialty, and treatment details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

1 yearcontinuation assessment threshold

least intensive settingadministration setting requirement

Coverage Criteria for Ocrevus (ocrelizumab)

Initial and continuation therapy criteria

Coverage considerations collected on the form to establish initial or continued medical necessity

Prescriber and indication: Medication prescribed by or in consultation with a neurologist or physician who specializes in multiple sclerosis when the diagnosis is a relapsing form of MS or primary progressive MS (or other indicated diagnosis)

Form requires prescriber specialty and diagnosis selection

New start vs continuation: Indicate whether this is a new start or continuation of Ocrevus; if continuation, indicate whether the patient has received at least 1 year of Ocrevus therapy>= 1 year for continuation assessment

Answer 'Yes' only if patient has received at least 1 year of therapy; restarting or <1 year = No

Objective response for continuation:

Policy Summary

PayerCigna

PolicyOcrevus (ocrelizumab) prior authorization and coverage form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the prior authorization form with required patient/provider fields and documentation of diagnosis, prescriber specialty, and treatment details.

SourceLink

On This Page

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Coding and Billing Requirements

Requested drug billing codemixed

J-code

J-code (field on form; specific HCPCS/J-code to be provided by requester)

NDC requirementNDC

NDC	NDC number required on medical claims to confirm drug payment for certain drugs (e.g., Betaseron)

inv-06: Minimum duration for continuation assessment

Minimum duration for continuation assessment>= 1 year of therapy (patient has received at least 1 year of Ocrevus) — answer No if patient has received less than 1 year or is restarting therapy

When to assessOnly applies when 'Currently receiving' is marked Yes on the form

Restarting therapyIf restarting Ocrevus, the patient is considered to have received <1 year for the purpose of continuation assessment

Provider Submission and Action Requirements

Documentation Required

Setting of Administration — Document and Consider Redirection

Per some Cigna plans, infusion of medication must occur in the least intensive, medically appropriate setting. If the infusion will not be provided in the least intensive appropriate setting, the patient may be a candidate for redirection (for example, to an alternate infusion site, physician's office, or home) with assistance from a Specialty Care Options Case Manager. If redirection is appropriate but not considered, coverage may be affected.

Affected action: consider and document the least intensive, medically appropriate setting for administration
If redirecting the patient, document discussion and medical necessity rationale

Prior Authorization

Required Submission Information — Complete All Asterisked Items

A completed prior authorization form must include all required patient and provider items denoted with an asterisk (*). Required information includes: patient name, Cigna ID, date of birth, physician DEA/NPI/TIN, physician name and specialty, and any other asterisked fields on the form. Also provide medication details (requested product, dose, quantity, J-code, frequency, duration), ICD-10 diagnosis, facility/dispensing provider information, and the NDC number on medical claims when applicable.

Include all asterisked patient and provider items on the form
Provide medication requested, dose, quantity, directions, J-code, frequency, duration, and ICD-10
Include facility/name, address, tax ID for dispensing/administration site
NDC number is required on medical claims when applicable to confirm claim payable

Documentation Required

Clinical and Combination Therapy Documentation

On the clinical information section, indicate whether the prescriber is a neurologist or MS specialist when applicable, whether Ocrevus will be used in combination with other disease‑modifying therapies (list examples on the form), and current Ocrevus treatment status (including duration of prior therapy if applicable).

Document prescriber specialty/consultation with neurologist or MS specialist
State whether Ocrevus will be used with other disease‑modifying agents and list those agents if applicable
If patient is currently receiving Ocrevus, indicate yes/no and whether they have received ≥1 year of therapy

Background on Ocrevus

Ocrevus (ocrelizumab) is indicated for relapsing forms of multiple sclerosis (examples include clinically isolated syndrome, relapsing‑remitting MS, and active secondary progressive MS) and primary progressive MS. The prior authorization form collects diagnosis and prescriber specialty (neurologist or MS specialist when applicable), whether the request is a new start or continuation, and objective measures of disease activity or response when assessing continuation of therapy.

For patients currently receiving Ocrevus, the form requires documentation of treatment duration and, when therapy has been administered for >= 1 year, evidence of benefit or stability by at least one objective measure (examples listed on the form include MRI activity, EDSS stability, NEDA status, relapse reduction, and other functional assessments) or documented clinical stabilization/improvement in a symptom domain.

Definitions and Outcome Measures

inv-13: Relapsing forms of multiple sclerosis

Relapsing forms includedClinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease

Other MS categories on formPrimary progressive multiple sclerosis is listed separately as a diagnosis option

Form useSelection of 'A relapsing form of multiple sclerosis' requires specifying one of the example relapsing conditions

inv-14: Objective measures of response

Examples of objective measuresMRI (absence or decrease in gadolinium‑enhancing lesions; decrease in new or enlarging T2 lesions); EDSS score stabilization or reduced worsening; achievement of NEDA‑3 or NEDA‑4

Functional and symptom measuresImprovement on FSIQ‑RMS (fatigue), reduction/absence of relapses, improvement/maintenance on 6‑minute walk test or 12‑Item MS Walking Scale

Composite and structural measuresImprovement on MSFC score and/or attenuation of brain volume loss

Alternate demonstration of benefitIf not meeting the objective measures above, documentation of stabilization, slowed progression, or improvement in at least one symptom domain (motor, fatigue, vision, bowel/bladder, spasticity, walking/gait, pain/numbness/tingling) is acceptable