CareCost Prior authorization
Required
Check what the payer requires before you schedule Ocrevus Zunovo.
Prior authorization · MS diagnosis coding · clinical criteria · site of care
27 payer policy sets hold an ocrelizumab policy, shared with infused Ocrevus · source-linked · reviewed September 2026
Aetna + relapsing forms of multiple sclerosis is shown as a live example until you choose a payer.
This payer requires an approval on file before Ocrevus Zunovo is purchased or administered for this member.
Precertification of multiple sclerosis medications (Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, Tysabri) are required of all Aetna participating providers
Covered under ICD-10 G35.
for members who have been diagnosed with a relapsing form of multiple sclerosis (including relapsing-remitting and secondary progressive disease
What opens in CareCost
Aetna · Ocrevus Zunovo · Relapsing-remitting MS
For every requirement: the exact payer criteria, the source citation, a check-off, and a save to the patient’s chart.
In CareCost: check off each requirement · save to the patient · print for the chart
Aetna · Ocrevus Zunovo · Relapsing-remitting MS
You have already checked the policy, indication and covered dose. Open the remaining requirements and work them as a patient checklist.
CareCost tracks Ocrevus Zunovo coverage requirements across 27 payer policy sets, shared with infused Ocrevus.
Aetna · Anthem / Elevance · Cigna · UnitedHealthcare · Regence · Highmark BCBS · BCBS plans + more
Coverage clearance is only the first step.
CareCost carries the same patient through the entire workflow.
Finish this patient’s estimate →23 of 27 commercial payers with an ocrelizumab policy require prior authorization. Clinical criteria, diagnosis coding and dosing rules vary by plan. CareCost has not found a payer in this corpus that carries no ocrelizumab policy at all — every payer checked has one.
23 require PA · 25 have clinical criteria · 10 restrict site of care · 8 list contraindication exclusions
23 of the 27 payers CareCost has read require an approval on file before ocrelizumab is covered. Aetna: “Precertification of multiple sclerosis medications (Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, Tysabri) are required of all Aetna participating providers.” BCBS Federal Employee Program ties the requirement to cost and safety: “Prior authorization is required to ensure the safe, clinically appropriate, and cost-effective use of the Ocrevus/Ocrevus Zunovo.” Four payers — HCSC, BCBS Kansas, Centene and Independence Blue Cross — carry no prior-authorization rule for ocrelizumab in this corpus.
Fifty-six rules name a diagnosis, and every one splits relapsing multiple sclerosis from primary progressive disease rather than treating the label as a single approval. Several payers write both Ocrevus and Ocrevus Zunovo into those criteria by name. UnitedHealthcare’s own policy language draws the ICD-10 line directly: primary progressive MS is billed to “G35.B0, G35.B1, G35.B2” while relapsing and active secondary progressive disease go to “G35.A, G35.C0, G35.C1, G35.C2, G35.D” — both under the heading “Ocrevus and Ocrevus Zunovo are medically necessary for the treatment of…” Anthem requires “a diagnosis of relapsing multiple sclerosis (RMS) (including clinically isolated syndrome, relapsing-remitting disease or active secondary progressive disease)” for one branch and “a diagnosis of primary progressive multiple sclerosis (PPMS)” for the other.
Aetna: “This medication must be prescribed by or in consultation with a neurologist.” BCBS Massachusetts requires “a board-certified or board eligible Neurologist.” Regence requires the diagnosis itself to be “established by a specialist in neurology or MS.”
Some payers require a documented trial of another disease-modifying MS drug first. BCBS Mississippi: the individual “has tried and failed… ONE of the following generic agents: Dimethyl fumarate; Fingolimod; Glatiramer; OR Teriflunomide.” Others gate on disease activity instead of prior therapy — BCBS Kansas requires an “Expanded Disability Status Scale (EDSS) score ≥ 3.0,” and Anthem requires the individual to be “able to ambulate more than 5 meters” or to have “experienced at least two relapses within the previous two years or one relapse within the previous year.”
BCBS Federal Employee Program names the product directly: “Complete HBV screening prior to the initiation of Ocrevus/Ocrevus Zunovo.” Arkansas BCBS puts the burden on the prescriber: “Prescriber is responsible for verification that Individual does not have latent tuberculosis, hepatitis B infection.” Several payers also require vaccination timing to be confirmed — Highmark BCBS: the individual “will not receive a live vaccine for at least four (4) weeks prior to and during treatment.”
Most policies bar stacking ocrelizumab with another disease-modifying MS drug. Aetna: members “will not use the requested drug concomitantly with other disease modifying multiple sclerosis agents” (Ampyra and Nuedexta excepted). CareFirst: “Members will not use Ocrevus concomitantly with other medications used for the treatment of multiple sclerosis, excluding Ampyra.” BCBS Nebraska goes further, prohibiting combinations across its entire MS drug list: “No therapies listed in this policy shall be used in combination with each other.”
10 of the 27 payers restrict where ocrelizumab can be administered, usually steering away from a hospital-affiliated outpatient department toward a physician office, freestanding infusion suite, or the patient’s home. Highmark BCBS names the approved settings directly: “administered in a physician’s office not affiliated with a hospital, specialized infusion centers not affiliated with a hospital or in the home.” These rules were written for a three-hour intravenous infusion; see below for what that means for the ten-minute subcutaneous injection.
Every dosing and quantity-limit rule CareCost has read for ocrelizumab caps the maintenance dose at 600 mg every 6 months — the infused Ocrevus regimen, given as two 300 mg loading infusions two weeks apart, then 600 mg every 6 months. None of them state a milligram limit for Ocrevus Zunovo’s 920 mg subcutaneous dose. A claim for 920 units checked mechanically against a rule keyed to “max_mg: 600” would flag as an overage; it isn’t one, it is a different product on a different code.
Approvals commonly run 12 months and require evidence of a treatment response to renew. Capital BlueCross: “Prior authorization validity may be renewed every 12 months thereafter,” contingent on “continuous monitoring showing a beneficial response to therapy.” BCBS Tennessee ties renewal to “disease stability or improvement while receiving the requested medication.”
Active hepatitis B infection and a history of a life-threatening infusion reaction are near-universal exclusions. UnitedHealthcare also names off-label uses it will not pay for: “Ocrevus and Ocrevus Zunovo are unproven and not medically necessary for the treatment of: Lupus nephritis, Rheumatoid arthritis, Systemic lupus erythematosus.” Anthem and Centene list the same three conditions separately.
Ocrevus (J2350, IV infusion) and Ocrevus Zunovo (J2351, subcutaneous injection) are both ocrelizumab, and payers write one medical policy that governs both. But the two bill on different codes, at different doses, in different settings — and the corpus does not always say which product a given rule was written with in mind.
| Product | Code | Rate/mg (Q3 2026) | Dose | Per dose | Per year (2 doses) |
|---|---|---|---|---|---|
| Ocrevus Zunovo (SC) | J2351 | $48.06 | 920 mg | $44,215.20 | $88,430.40 |
| Ocrevus (IV) | J2350 | $60.97 | 600 mg | $36,582.00 | $73,164.00 |
| Briumvi (IV) — a different molecule, shown for scale | J2329 | $72.239 | 450 mg | $32,507.55 | $65,015.10 |
J2351’s per-mg rate is $12.91 cheaper than J2350’s, and the subcutaneous product still costs $15,266.40 more per year, because the labeled dose is 920 mg against 600 mg. Briumvi is ublituximab-xiiy, made by TG Therapeutics — a different molecule, not a substitute CareCost is recommending; it appears here only so the size of these numbers has something to compare against.
Multiple sclerosis carried a single ICD-10 code, G35, until it was expanded into billable child codes. A claim coded to the parent G35 alone will be rejected. Ten pages elsewhere on this site still cite the parent code alone — do not add an eleventh.
| ICD-10 | Description |
|---|---|
G35.A | Relapsing-remitting multiple sclerosis |
G35.B0 | Primary progressive multiple sclerosis, unspecified |
G35.B1 | Primary progressive multiple sclerosis, active |
G35.B2 | Primary progressive multiple sclerosis, non-active |
G35.C0 | Secondary progressive multiple sclerosis, unspecified |
G35.C1 | Secondary progressive multiple sclerosis, active |
G35.C2 | Secondary progressive multiple sclerosis, non-active |
G35.D | Multiple sclerosis, unspecified |
Verified against the NLM Clinical Table Search Service. CareCost is not stating an effective date for the expansion — Ocrevus’s own manufacturer page cites one CareCost could not confirm against a primary source, so it is left out here rather than repeated.
The corpus supports this split independently: UnitedHealthcare’s ocrelizumab policy routes primary progressive MS to “G35.B0, G35.B1, G35.B2” and relapsing plus active secondary progressive disease to “G35.A, G35.C0, G35.C1, G35.C2, G35.D.” This tool maps relapsing forms of MS to G35.A, primary progressive MS to G35.B1 (active), and active secondary progressive MS to G35.C1. G35.B0/B2, G35.C0/C2 and G35.D cover clinical states — unspecified or non-active disease — that this picker does not model; use the table above for those.
Coverage follows the diagnosis codes and local coverage determinations published in the CMS Medicare Coverage Database, and a MAC can differ from its neighbor on the same drug. J2351 received a permanent HCPCS code on 1 April 2025 — more recent than most drugs in this corpus — so local coverage language specific to the subcutaneous product may still be catching up in some jurisdictions. Check the governing LCD for this patient’s MAC rather than assuming Medicare treats J2350 and J2351 identically.
This is the Original Medicare answer. A Medicare Advantage plan administers the same Part B benefit but can layer its own prior-authorization and site-of-care rules on top — check the plan’s own policy rather than assuming the Original Medicare rules carry over.
96401 (subcutaneous non-hormonal anti-neoplastic injection, national non-facility rate $71.81) and 96372 (therapeutic subcutaneous injection, $15.36) are both in use for the same roughly ten-minute Ocrevus Zunovo injection — a 4.7× spread on the administration line decided by payer policy rather than by what happens in the chair. The reference calculation on this site uses 96401, the code Genentech’s own billing guidance leads with. This is documented, not settled — confirm the payer’s position before the first claim rather than assuming either code.
Payer citation language above is drawn from CareCost’s own ocrelizumab policy corpus (27 payers, 251 rules). Check the specific payer’s language →
It depends on the payer and plan. 23 of the 27 commercial ocrelizumab policies CareCost has read require prior authorization before Ocrevus or Ocrevus Zunovo is covered. Four payers — HCSC, BCBS Kansas, Centene and Independence Blue Cross — carry no prior-authorization rule for ocrelizumab. Check this patient’s payer →
Not the bare G35. Multiple sclerosis was expanded into billable child codes: G35.A for relapsing-remitting disease, G35.B0/B1/B2 for primary progressive MS, G35.C0/C1/C2 for secondary progressive MS, and G35.D for unspecified MS. A claim coded to the parent G35 alone will be rejected. Check the diagnosis coding →
Not directly. None of the 251 ocrelizumab rules CareCost has read are filed under Ocrevus Zunovo’s own code, J2351 — 210 are filed under Ocrevus’s J2350 and 41 carry no HCPCS code at all. Nine payers name “Ocrevus Zunovo” by brand inside their policy text, which is the clearest evidence a rule is meant to bind both products, but site-of-care and quantity-limit language elsewhere was written around an intravenous infusion. See what the corpus does and doesn’t say →
CareCost turns the applicable payer policy into a patient-level checklist showing each requirement, what to confirm, and the source language supporting it. Open patient clearance →
Data current: payer policies Aug 2026 · reviewed dates come from each payer
Payer medical and pharmacy policies · prior-authorization criteria · clinical coverage criteria. ICD-10 codes verified against the NLM Clinical Table Search Service. Medicare coverage and fee-schedule amounts from the CMS Medicare Coverage Database and the Medicare Physician Fee Schedule. Every CareCost requirement links back to its source policy.