CurrentMass General Brigham Health PlanPolicy N/A

Ocrevus (ocrelizumab) and Ocrevus Zunovo coverage

Prior authorization, quantity limits, and continuation criteria for Ocrevus (ocrelizumab) and Ocrevus Zunovo (ocrelizumab with hyaluronidase) for adults with relapsing or primary progressive multiple sclerosis; applies to Mass General Brigham Health Plan members and specialty pharmacy dispensing.

Policy Summary

PayerMass General Brigham Health Plan

PolicyOcrevus (ocrelizumab) and Ocrevus Zunovo coverage

Policy CodePolicy N/A

Change TypeAdded Zunovorevised diagnosis/concomitant therapy language

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of an FDA‑approved MS diagnosis to request approval for Ocrevus or Ocrevus Zunovo.

SourceLink

POLICY UPDATE CHANGES

Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) was added to the policy and is covered at parity with Ocrevus.

Diagnosis language was streamlined and the requirement that the member is not using the requested medication concomitantly with other disease modifying MS agents was removed.

12 monthsapproval duration

2 vials / 24 wksOcrevus vial limit

1 vial / 24 wksZunovo vial limit

90 days

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Coverage Criteria for Ocrevus and Ocrevus Zunovo

Initial Authorization - Qualifying Diagnoses

Authorization may be granted when the following criteria is met:

Qualifying diagnoses: Member has one of the following diagnoses: (a) Relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting and secondary progressive disease) OR (b) Primary progressive multiple sclerosis.

Supports initial authorization

Continuation of Therapy

Requests for reauthorization will be approved when the following criteria are met:

Continuation of therapy: Member is experiencing disease stability or improvement.

Required for reauthorization

This policy does not list specific drug exclusions for Ocrevus or Ocrevus Zunovo. Members who are new to the plan within the past 90 days and are already receiving the requested medication may be authorized to continue therapy, provided the medication was not obtained as samples or through a manufacturer's patient assistance program. Providers should document prior treatment status and the source of the drug supply when requesting authorization for continuity of care.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required for Ocrevus and Ocrevus Zunovo

Prior authorization is required for Ocrevus (ocrelizumab) and Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq); approvals are granted when the member meets the policy's qualifying MS diagnosis criteria.

Note

New-member continuity (90 days)

Members who are new to the plan and have been receiving the requested medication within the past 90 days may be authorized to continue therapy; samples and manufacturer patient assistance program supplies are excluded.

Step Therapy

Step therapy noted — no explicit steps specified

The policy lists Step Therapy as a program type but does not specify any required prior agent(s) or explicit step requirements in the policy text.

Definitions

Relapsing forms of MS — definition

DefinitionRelapsing forms of multiple sclerosis include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease in adults.

Included clinical presentationsClinically isolated syndrome (first clinical episode suggestive of MS).

Included disease courseRelapsing‑remitting multiple sclerosis (RRMS).

Progressive form with activityActive secondary progressive multiple sclerosis (SPMS) — secondary progressive disease with relapses or new inflammatory activity.

Primary progressive MS — definition

DefinitionPrimary progressive multiple sclerosis (PPMS) — a form of MS characterized by steady worsening of neurologic function from disease onset without early relapses, indicated for adults.

Background

Ocrelizumab (Ocrevus) is a monoclonal antibody approved for adults with relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease) and for primary progressive multiple sclerosis. Ocrevus Zunovo combines ocrelizumab with hyaluronidase to allow subcutaneous delivery and is addressed in this policy at parity with intravenous Ocrevus.

Prior authorization is required for Ocrevus and Ocrevus Zunovo. Authorization for initial treatment is granted when the member has a qualifying diagnosis of either relapsing forms of MS or primary progressive MS; reauthorization requires documentation that the member is experiencing disease stability or improvement.