CurrentHighmark DelawarePolicy N/A

Outpatient Ocrevus (ocrelizumab) authorization request

This form governs prior authorization requests for outpatient administration of Ocrevus (ocrelizumab) for Highmark Delaware members and must be completed by the ordering provider or infusion supplier.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Ocrevus (ocrelizumab) authorization request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization using the outpatient Ocrevus form with HCPCS J2350 and attach required clinical documentation (MRI/CSF results, last infusion date, and neurologist involvement).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

FaxSubmission method

J2350HCPCS code listed

4Site of service options

Relapsing / PPMS / OtherDiagnosis options

Pre-infusion checksClinical documentation requested

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Coverage Criteria for Ocrevus (ocrelizumab)

Authorization Criteria

Covered when ALL of the following are met and documented on the form:

Diagnosis

Relapsing vs PPMS: Check the appropriate diagnosis box on the form (Relapsing Form of MS OR Primary Progressive MS based on McDonald criteria)
Chunk 4 provides diagnosis options

Objective Diagnostic Evidence for MS

MRI or CSF: MRI consistent with MS OR CSF evidence of intrathecal IgG/oligoclonal bands
See MRI question and McDonald CSF criterion (chunks 5 and 4)

Prescribing Provider: Ocrevus prescribed by or in consultation with a neurologist or provider who specializes in MS

Form contains explicit question confirming specialist involvement

Safety Checks: Documentation that member does not have active Hepatitis B infection and that live vaccines were not given within 4 weeks prior to or during treatment

Form asks about active Hep B and live vaccines

Treatment Reporting: Indicate new start versus continuation and provide date of last infusion; for continuation, document positive clinical response if requested

Form requests new start vs continuation, last infusion date, and asks about documented positive clinical response

Concurrent Therapy Declaration: Declare whether the member is receiving Ocrevus in combination with another disease-modifying therapy

Form asks and requires documentation if combination therapy is being used

The authorization form asks providers to indicate if the member is receiving Ocrevus in combination with another disease‑modifying therapy. Concurrent administration must be declared on the form; the form does not provide a separate approval pathway or explicit criteria for combination therapy beyond documentation of concurrent use.

Use that lacks the required diagnostic or safety documentation identified on the form should be flagged. Specifically, the form requires documentation that the member has an MRI of the brain showing abnormalities consistent with multiple sclerosis or, where applicable for PPMS, CSF evidence; confirmation that Ocrevus is prescribed by or in consultation with a neurologist or MS specialist; confirmation that the member does not have active Hepatitis B; and confirmation that no live vaccines will be given within 4 weeks prior to or during treatment. Absence of these items would not meet the form's authorization expectations.

Billing and Diagnosis Codes

Drug HCPCS CodeHCPCSCovered

J2350

OCREVUS (ocrelizumab) listed on form

Diagnosis Codes (ICD-10)ICD-10

ICD-10

Diagnosis code — field for ICD-10 provided on the form (specific codes to be entered by provider)

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization must be requested using the outpatient Ocrevus authorization form. Include the HCPCS code J2350 and all requisite clinical attachments when submitting the request.

Use the Outpatient Medical Injectable Ocrevus Authorization Request Form
Include HCPCS J2350 (OCREVUS) on the form
Fax completed form and attachments to 833-581-1861

Documentation Required

Concurrent Therapy Reporting

The form asks whether Ocrevus is being used in combination with another disease‑modifying therapy. If the member is receiving combination therapy, the provider must declare this on the form and include supporting documentation explaining the rationale and safety monitoring.

Declare combination therapy on the form (checkbox for receiving Ocrevus with another DMT)

Background

Ocrevus (ocrelizumab) is an infused, disease‑modifying therapy used for treatment of multiple sclerosis. The authorization form captures the clinical information needed to support use for either relapsing forms of MS or primary progressive MS, including documentation of MRI findings consistent with MS or CSF evidence where applicable, confirmation that a neurologist or MS specialist is prescribing or consulted, safety checks such as screening for active Hepatitis B and timing of live vaccines, and whether the request is a new start or continuation (with date of last infusion and clinical response for continuation).

Definitions

McDonald criteria for PPMS

Definition (McDonald criteria for PPMS)One or more years of progressive neurologic worsening plus at least two of the following: (1) ≥1 T2 lesion in at least one brain area characteristic for MS (periventricular, juxtacortical, or infratentorial); (2) ≥2 T2 lesions in the spinal cord; (3) documented elevated CSF IgG index or CSF oligoclonal bands.

Time requirementProgressive neurologic symptoms present for one or more years.

Brain MRI requirementEvidence of dissemination in space in the brain: ≥1 T2 lesion in a characteristic area (periventricular, juxtacortical, or infratentorial).

Spinal cord MRI requirementEvidence of dissemination in space in the spinal cord: ≥2 T2 lesions in the cord.

CSF requirementDocumented history or presence of elevated CSF IgG index or CSF oligoclonal bands fulfills a McDonald criterion.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Ocrevus (ocrelizumab) authorization request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization using the outpatient Ocrevus form with HCPCS J2350 and attach required clinical documentation (MRI/CSF results, last infusion date, and neurologist involvement).

SourceLink

On This Page

Attach clinical rationale and documentation for combination use

Documentation Required

Required Documentation

Required documentation includes the completed authorization form with member and provider information, drug name (OCREVUS), HCPCS code J2350, strength/dose, date of service, quantity, diagnosis code (ICD-10), supplier information (specialty pharmacy or Buy & Bill), and all pertinent clinical attachments (MRI reports, neurologist consultation, Hepatitis B testing, vaccination history, prior infusion dates, and documentation of clinical response).

Member name, DOB, Member ID (UMI) and contact information
Physician name and NPI, office contact, phone and fax
Drug name OCREVUS (J2350), strength/dose, date of service, directions, quantity
Diagnosis code (ICD-10)
Drug supplier selection: Specialty Pharmacy (name & NPI) or Buy & Bill
Pertinent clinical attachments: MRI consistent with MS, neurologist consultation, Hepatitis B status, vaccine history, prior infusion dates, documentation of clinical response
Specify New Start or Continuation of Therapy

Denial Risk

Form and Documentation Completeness

Incomplete form fields or missing attachments may lead to denial or delay. Ensure member ID, diagnosis code, drug name/dose/service date, supplier information, and all requested clinical documents are present and legible.

Missing member ID, diagnosis code, or provider NPI may delay processing
Omitted drug details (name, dose, date of service) or supplier selection can result in denial
Ensure MRI reports, specialist consultation, and Hepatitis B testing are attached when indicated