CurrentEmblemHealthPolicy MG.MM.PH.302

Ocrevus (ocrelizumab) intravenous infusion

Clinical coverage criteria and authorization guidance for Ocrevus (ocrelizumab) IV for treatment of adults with multiple sclerosis, directed to providers requesting coverage from EmblemHealth/ConnectiCare.

Policy Summary

PayerEmblemHealth

PolicyOcrevus (ocrelizumab) intravenous infusion

Policy CodePolicy MG.MM.PH.302

Change TypeAnnual review — removed G35.2 and G35.1no criteria changes

Effective Date

Next Review DateMar 10, 2025

Key ActionSubmit clinical evidence that the member meets policy criteria to EmblemHealth/ConnectiCare for prior authorization.

SourceLink

POLICY UPDATE CHANGES

Annual Review: removed G35.2 and G35.1. No criteria changes.

12 monthsAuthorization length

300/600 mgAllowed dosing regimens

>18 yrsAge requirement

J2350HCPCS

Coverage Criteria for Ocrevus (ocrelizumab)

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.

ALL of the following

Patient is > 18 years of age.
Patient has a relapsing form of multiple sclerosis (examples include clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease).
Patient meets one of the following:
- Patient experienced a beneficial clinical response when assessed by at least one objective measure (examples include stabilization or reduced worsening in disease activity on MRI such as absence or decrease in gadolinium‑enhancing lesions or decrease in number of new/enlarging T2 lesions; stabilization or reduced worsening on the Expanded Disability Status Scale [EDSS]; achievement of NEDA‑3 or NEDA‑4; improvement on FSIQ‑RMS; reduction or absence of relapses; improvement/maintenance on the six‑minute walk test or 12‑Item MS Walking Scale; improvement on MSFC; attenuation of brain volume loss).
- Patient experienced stabilization, slowed progression, or improvement in at least one symptom such as motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or sensory symptoms (pain/numbness/tingling).
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approvals are issued for up to 12 months when the clinical criteria are met.

Length of authorization: 12 months

Documentation Required

Required clinical documentation

The treating physician or primary care provider must submit clinical evidence that the member meets the policy criteria for the requested treatment. This documentation is required for preauthorization review and for any post-payment review; without it EmblemHealth cannot properly evaluate the request.

Clinical evidence should document age, diagnosis, disease course, prior response or intolerance to therapy (if applicable), objective measures of benefit or progression, and any other information referenced in the coverage criteria.

Documentation Required

Clinical and prescriber qualifications

Documentation should confirm the member’s age, the specific diagnosis (including relapsing form of multiple sclerosis or primary progressive as applicable), and that the medication is prescribed by or in consultation with a neurologist or a physician who specializes in multiple sclerosis when required by the criteria.

Confirm patient is > 18 years of age when required by criteria
Document relapsing MS subtype when applicable (e.g., clinically isolated syndrome, relapsing‑remitting, active secondary progressive)
Include statement that medication is prescribed by or in consultation with a neurologist or MS specialist when required

Denial Risk

Incomplete documentation may result in denial

Failure to provide complete clinical documentation necessary to demonstrate that the member meets the policy criteria may result in denial of the request.

Incomplete or missing supporting records (e.g., clinic notes, MRI reports, objective outcome measures) may delay review or cause denial

Denial Risk

Concurrent disease‑modifying therapies — not recommended

Requests for concurrent use of Ocrevus with other disease‑modifying therapies for multiple sclerosis are not recommended. Concurrent DMT therapy is generally not indicated and such requests may be denied.

Examples of other DMTs: teriflunomide, interferons, fingolimod, glatiramer acetate, ofatumumab, alemtuzumab, cladribine, siponimod, natalizumab, and others listed in the policy

Definitions

Ocrevus (ocrelizumab) — key drug facts, dosing overview

Generic nameocrelizumab

Brand nameOcrevus

Mechanism of actionCD20-directed cytolytic monoclonal antibody

Approved indications (adult)Relapsing forms of multiple sclerosis and Primary progressive multiple sclerosis

Dosing — initial regimenTwo 300 mg IV infusions: first dose followed by a second 300 mg dose 2 weeks later (300 mg on day 1 and day 15)

Dosing — maintenance regimen600 mg IV infusion once every 6 months

Billing units / HCPCS guidanceJ2350: ocrelizumab, 1 mg (billable units correspond to mg administered)

Relapsing forms of MS — definition and examples

DefinitionRelapsing forms of multiple sclerosis include clinically isolated syndrome, relapsing‑remitting MS, and active secondary progressive MS as listed in the policy.

Age requirementAdults >18 years of age (policy applies to patients older than 18)

Examples of clinical presentationClinically isolated syndrome; relapsing‑remitting disease; active secondary progressive disease

Objective measures used to assess response (examples)MRI activity (absence or decrease in gadolinium‑enhancing lesions, fewer new/enlarging T2 lesions), EDSS stabilization, NEDA‑3/NEDA‑4, reduced relapses, functional tests (6‑minute walk, MSFC), reduced brain volume loss

Symptom domains considered for clinical benefitMotor function, fatigue, vision, bowel/bladder, spasticity, walking/gait, pain/numbness/tingling

OpenPayer

Ocrevus (ocrelizumab) intravenous infusion

Coverage Criteria for Ocrevus (ocrelizumab)

Applicable Codes

Provider Actions and Documentation Requirements

Background

Definitions