CurrentEmblemHealthPolicy MG.MM.PH.429

Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) subcutaneous injection

Defines EmblemHealth coverage criteria, dosing, authorization length, exclusions, applicable billing codes and NDC for Ocrevus Zunovo (ocrelizumab + hyaluronidase) subcutaneous injection for adult multiple sclerosis (relapsing forms and primary progressive).

Policy Summary

PayerEmblemHealth

PolicyOcrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) subcutaneous injection

Policy CodePolicy MG.MM.PH.429

Change TypeNew policy

Effective DateJan 30, 2025

Next Review Date

Key ActionTreating physician or PCP must submit clinical evidence that the member meets the specified criteria for coverage; EmblemHealth will not review without this documentation.

SourceLink

POLICY UPDATE CHANGES

New policy established for Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) subcutaneous injection.

12 monthsAuthorization Duration

≥ 18Minimum Age (years)

920 mg / 23,000 unitsApproved Dose

Coverage Summary

Defines EmblemHealth coverage criteria for Ocrevus Zunovo (ocrelizumab + hyaluronidase) subcutaneous injection in adults with multiple sclerosis. Policy covers relapsing forms of MS and primary progressive MS in patients aged ≥ 18, specifies the subcutaneous formulation Ocrevus Zunovo with hyaluronidase, and provides an authorization length of 12 months.

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Approved Indications and Therapy Criteria

Approved Indications and Initial/Continuation Criteria

Approve when the following structured criteria are met for relapsing MS or primary progressive MS as specified:

Relapsing Forms - Initial OR Continuing Therapy

A. Initial Therapy (approve for 1 year)
- 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.
- Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis
B. Currently Receiving Ocrevus for ≥ 1 Year (continuation)
- 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 multiple sclerosis.
- Clinical benefit requirement
  - 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 (absence or decrease in gadolinium enhancing lesions; decrease in new or enlarging T2 lesions); stabilization or reduced worsening on EDSS; achievement of NEDA-3 or NEDA-4; improvement on FSIQ-RMS; reduction/absence of relapses; improvement/maintenance on six-minute walk test or 12-Item MS Walking Scale; improvement on MSFC score; 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 pain/numbness/tingling sensation

Primary Progressive Multiple Sclerosis

Patient is ≥ 18 years of age
Ocrevus is prescribed by or in consultation with a physician who specializes in the treatment of multiple sclerosis and/or a neurologist

Provider Actions & Authorization Requirements

Prior Authorization

Preauthorization and Clinical Documentation Requirement

Treating physician or PCP must submit clinical evidence that the member meets the specified criteria for coverage; EmblemHealth will not review without this documentation.

J3590
50242-0554-01

Documentation Required

Prescriber Specialty Requirement

Medication must be prescribed by or in consultation with a neurologist or a physician who specializes in MS for all approved indications.

Billing Rule

Length of Authorization

Coverage will be provided for 12 months and can be renewed.

Denial Risk

Concurrent Disease-Modifying Therapies Not Allowed

Coverage not recommended for concurrent use with other disease-modifying agents for MS (lists multiple agents); requests for combination therapy risk denial.

Background

Background: Ocrevus (ocrelizumab) is a CD20-directed cytolytic antibody indicated for relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing remitting MS, and active secondary progressive MS) and primary progressive MS in adults. This policy specifically covers the subcutaneous formulation Ocrevus Zunovo with hyaluronidase (NDC 50242-0554-01).

Definitions

Relapsing forms of multiple sclerosisIncludes clinically isolated syndrome, relapsing remitting MS, and active secondary progressive MS.

Revision History

2025-01-30policy addedLatest

New policy established for Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) subcutaneous injection.

2025-01-30revision history

Revision history indicates new policy effective 01/30/2025.

2025-01-30coverage details

Policy defines coverage criteria and dosing for Ocrevus Zunovo 920 mg / 23,000 units subcutaneously every 6 months and specifies authorization for 12 months.