CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Ocrevus (ocrelizumab) Authorization — Coverage Criteria

This form governs prior authorization requests for outpatient administration of Ocrevus (ocrelizumab) for members covered by Highmark BlueShield entities; it is used by ordering providers/site of care to request authorization and document clinical information.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Ocrevus (ocrelizumab) Authorization — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed outpatient Ocrevus authorization form including HCPCS J2350, dose, diagnosis, site of care, and required clinical attachments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

J2350drug and HCPCS code listed on form

MS/MRI/HepBclinical checklist

Locationsite of care fields

Coverage Criteria for Ocrevus (ocrelizumab)

Initial or continuation therapy authorization criteria

Covered when ALL of the following are documented on the authorization form

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Ocrevus (ocrelizumab) Authorization — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed outpatient Ocrevus authorization form including HCPCS J2350, dose, diagnosis, site of care, and required clinical attachments.

SourceLink

On This Page

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.

Primary coverage criteria: 1) Diagnosis of relapsing forms of multiple sclerosis (including relapsing‑remitting, active secondary progressive disease, or clinically isolated syndrome) OR primary progressive multiple sclerosis based on McDonald criteria (see form); 2) Documentation of an MRI of the brain showing abnormalities consistent with multiple sclerosis; 3) Ocrevus is prescribed by or in consultation with a neurologist or a provider who specializes in treatment of multiple sclerosis; 4) No active Hepatitis B virus infection documented; 5) No live vaccines administered within 4 weeks prior to or during treatment; 6) Member is not receiving Ocrevus in combination with another disease‑modifying therapy for MS; 7) For continuation requests: documentation of a positive clinical response (e.g., reduction in relapse rate, delay or improvement in disability progression, or reduction in MRI lesion number/volume) is provided.

All items are requested by the authorization form to support coverage.

The authorization form asks whether the member is receiving Ocrevus in combination with another disease-modifying therapy for multiple sclerosis. Concurrent use is specifically queried because it may preclude coverage; if the member is receiving another disease-modifying therapy in combination with Ocrevus, this may be an exclusion to authorization and should be clearly documented and justified on the form.

The form requires documentation that the member does not have an active Hepatitis B virus infection and asks whether the member will receive any live vaccines within 4 weeks prior to or during treatment. Use of Ocrevus in combination with another disease-modifying therapy, or administration despite active Hepatitis B infection or recent live vaccination, is specifically queried and may be considered not medically necessary or contraindicated.

Coding (HCPCS / ICD-10)

Covered HCPCS / drug code listedHCPCSCovered

J2350

OCREVUS (ocrelizumab) outpatient injectable code as listed on form

Diagnosis codes (ICD-10) — provider suppliedICD-10

ICD-10

Diagnosis code field (specific codes not listed on form; provider to supply appropriate MS code)

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient injectable Ocrevus (HCPCS J2350). Requests must be submitted using the Outpatient Medical Injectable Ocrevus Authorization Request Form and include the HCPCS code J2350, dose/strength, quantity, date of service, and site of care information. Fax completed forms to 833-581-1861. Verify member eligibility and benefits through the health plan prior to submission.

Form: Outpatient Medical Injectable Ocrevus Authorization Request Form
HCPCS: J2350 (OCREVUS)
Fax: 833-581-1861
Include: dose/strength, date of service, quantity (# of doses/visits), place of service, NPI, Tax ID, billing type (facility or professional)

Documentation Required

Required Documentation

Completed authorization form must include member demographics and identifiers, provider and site-of-care details, drug name and HCPCS code (OCREVUS J2350) with strength/dose, directions, quantity (number of doses/visits), date of service, and diagnosis code (ICD-10). If supplied by a specialty pharmacy for home infusion, include pharmacy name and NPI. Attach all pertinent clinical documentation requested on the form.

Member name, DOB, Member ID (UMI), address
Provider: place of service name, NPI, Tax ID, phone, fax
Site of care: Home Infusion / Office Professional / Ambulatory Infusion Suite / Outpatient Hospital; indicate if billed as facility
Drug: OCREVUS (J2350) — strength/dose, directions, quantity, date of service
Diagnosis code (ICD-10)
Specialty pharmacy info (if applicable): Pharmacy name, Pharmacy NPI
Attach: MRI reports, neurologist consultation notes, treatment response documentation, Hepatitis B testing/results, vaccination history

Step Therapy

Step / Continuation Therapy Checks

The form asks whether Ocrevus is a new start or continuation of therapy and requires documentation of clinical response for continuation requests. For continuation, include evidence of a documented positive clinical response (for example: reduction in annualized relapse rate, confirmed delay or improvement of disability progression, or reduction in number/volume of MRI lesions). The form also asks whether Ocrevus is being given in combination with another disease-modifying therapy.

Indicate: New Start or Continuation of Therapy
For Continuation: provide documentation of positive clinical response (e.g., relapse reduction, disability improvement/delay, MRI lesion reduction)
State whether Ocrevus is being used in combination with another disease-modifying therapy for MS

Denial Risk

Triggers for Potential Denial

Applications may be denied or delayed if required documentation is missing or if clinical exclusion criteria are present. Common triggers for potential denial include absence of MRI evidence consistent with multiple sclerosis, lack of neurologist involvement or specialist consultation, active Hepatitis B infection, planned receipt of live vaccines within 4 weeks prior to or during treatment, concurrent use with another disease-modifying therapy without justification, or failure to attach requested clinical records.

No MRI documentation consistent with MS
Prescribing provider is not a neurologist or treatment not in consultation with a neurologist/specialist
Active Hepatitis B infection present
Receipt or planned receipt of live vaccines within 4 weeks prior to or during Ocrevus treatment
Concurrent use of Ocrevus with another disease-modifying therapy without documentation
Required clinical attachments not provided (e.g., MRI reports, treatment response evidence)

Background

Ocrevus (ocrelizumab) is indicated for relapsing forms of multiple sclerosis and primary progressive multiple sclerosis. For primary progressive MS the form expects documentation consistent with diagnostic standards (e.g., McDonald criteria), and the authorization process requests supporting clinical information such as MRI findings, specialist involvement, and evidence of progressive neurologic worsening or other diagnostic data to support the diagnosis.

Definitions

McDonald criteria — primary progressive MS

Required duration of progressive neurologic worseningOne or more years of neurologic symptoms typical of multiple sclerosis progressively worsening

Brain lesion dissemination criterion≥1 T2 lesion in at least one characteristic brain area (periventricular, juxtacortical, or infratentorial); gadolinium enhancement not required

Spinal cord lesion dissemination criterion≥2 T2 lesions in the spinal cord; gadolinium enhancement not required

CSF criterionDocumented history or presence of elevated CSF IgG index or CSF oligoclonal bands

McDonald criteria applicationPrimary progressive MS diagnosis must meet McDonald criteria (combination of progressive course ≥1 year plus at least two of the listed dissemination/CSF findings)