CareCost Prior authorization
Required
Check what the payer requires before you schedule Ocrevus.
27 payers, 251 rules, and 8 of them require a generic DMT first.
27 payer policy sets hold an ocrelizumab policy · source-linked · reviewed August 2026
Aetna + Relapsing MS is shown as a live example until you choose a payer.
This payer requires an approval on file before Ocrevus is purchased or infused 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 · Relapsing 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 · Relapsing 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 coverage requirements across 27 payer policy sets.
Aetna · Anthem / Elevance · UnitedHealthcare · Cigna · CareFirst 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. Every payer in this corpus documents a covered MS diagnosis and the labeled dose before Ocrevus is paid; the generic-DMT-first requirement, site-of-care rules and reauthorization timing vary by plan.
The 251 rules break out as 113 clinical prerequisites, 56 covered-indication rules (roughly two per payer, split between Ocrevus’s relapsing and primary progressive policy sets), 24 prior-authorization rules, 19 dosing rules, 15 contraindication exclusions, 11 site-of-care rules, 6 quantity limits, 4 reauthorization rules, 2 combination rules and 1 step-therapy rule.
23 require PA · 27 have clinical criteria · 10 restrict site of care
23 of the 27 payers CareCost has read require an approval on file before ocrelizumab is covered. Aetna’s precertification rule reads: “Precertification of multiple sclerosis medications (Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, Tysabri) are required of all Aetna participating providers.” The other 4 apply the same clinical review without a formal prior-authorization label; the documentation burden is the same either way.
8 of the 27 payers in this corpus will not approve Ocrevus until a generic disease-modifying therapy has been tried, failed or ruled out, and it is never a competing anti-CD20 antibody — always a plain generic DMT. BCBS Mississippi: “The individual has tried and failed (see definition of Medication Failure in Policy Guidelines section) ONE of the following generic agents” — failure of one generic disease-modifying therapy: dimethyl fumarate, fingolimod, glatiramer or teriflunomide. Regence: treatment with at least one low-cost DMT that was ineffective, not tolerated or contraindicated. Excellus: “The patient must have had serious side effects or drug failure of at least two medications (oral or self-injectable) indicated for the treatment of multiple sclerosis (minimum 12-week trials).” Centene requires failure of dimethyl fumarate, teriflunomide, fingolimod, and an interferon-beta agent or glatiramer for adults: “Failure of all of the following at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated.” Anthem, BCBS Kansas and BCBS South Carolina all require “a trial and failure of preferred therapy” in similar language; BCBS Tennessee states it plainly: “Requires Step Therapy.” The other 19 payers in this corpus do not name a required drug ahead of Ocrevus.
11 of the 251 rules in this corpus, at 10 different payers, touch where the infusion happens, and none of them limit Ocrevus to a single setting outright. Aetna: “Site of Care Utilization Management Policy applies for Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, and Tysabri.” Florida Blue adds a condition specifically for the hospital: “If ocrelizumab (Ocrevus, Ocrevus Zunovo) is administered in a hospital-affiliated outpatient setting, additional requirements may apply depending on the member’s benefit.” Blue Shield of California names its preferred settings: “the home, a physician’s office, or an independent infusion center.” Highmark allows “a physician’s office not affiliated with a hospital, specialized infusion centers not affiliated with a hospital or in the home.” BCBS South Carolina and Arkansas BCBS both route the review to a separate site-of-care policy; Regence applies its own site-of-care policy manual (dru408) to both the relapsing and primary progressive rules.
Ocrevus is the only anti-CD20 antibody the FDA has labeled for this indication, and every payer in this corpus tracks it that way: primary_progressive_multiple_sclerosis is a separate clearance key from multiple_sclerosis, held by all 27 payers independently of the relapsing-disease rules. A payer’s prior-authorization, site-of-care and reauthorization rules generally apply the same way to both keys, but the covered-indication language is written and reviewed separately for each.
6 of the 251 rules in this corpus cap the dose or the authorization period, and every one of them restates the FDA-labeled schedule rather than cutting it. BCBS Kansas: “Subsequent doses: single 600 mg intravenous infusion every 6 months.” Capital BlueCross: “300 billable units (300 mg) on day 1 and day 15” for the initial infusions. Wellmark: “Maintenance: 600 mg every 6 months.” BCBS Mississippi ties its limit to the label directly: “within the program quantity limits based on FDA approved labeled dosage.” Centene states the review window instead of the milligrams: “Commercial – 6 months or to the member’s renewal date, whichever is longer.” None of the six rules restrict Ocrevus below what the label allows.
4 of the 251 rules set a renewal term, and every one of them lands on the same interval. BCBS Mississippi: “Length of Approval: 12 months.” Capital BlueCross: “Prior authorization validity may be renewed every 12 months thereafter.” BCBS Tennessee ties the 12-month renewal to a clinical check: “Authorization of 12 months may be granted for all members (including new members) who achieve or maintain a positive clinical response as evidenced by experiencing disease stability.” Centene renews on the same standard: “Member is responding positively to therapy.” Because Ocrevus is dosed every 6 months, a 12-month authorization covers exactly two maintenance infusions before the chart has to be reopened.
Two payers in this corpus write a prerequisite specific to patients 10 to 17 with relapsing-remitting MS. Centene: “Failure of fingolimod (Gilenya), unless contraindicated or clinically significant adverse effects are experienced.” Excellus requires the same kind of documented failure or intolerance to fingolimod before a pediatric start. Both apply on top of the label’s own weight-based dosing split at 35 kg.
Not a competing anti-CD20 antibody — a plain generic disease-modifying therapy, tried, failed or ruled out before ocrelizumab.
| Payer | What comes first |
|---|---|
| BCBS Mississippi | Failure of one of dimethyl fumarate, fingolimod, glatiramer or teriflunomide (or signs of highly active disease) |
| Regence | At least one low-cost DMT ineffective, not tolerated, or contraindicated |
| Excellus | Failure or intolerance of at least two prior MS therapies (12-week trials each) |
| Centene (adult) | Failure of dimethyl fumarate, teriflunomide, fingolimod, and an interferon-beta agent or glatiramer |
| Centene, Excellus (pediatric) | Failure of fingolimod |
| Anthem, BCBS Kansas, BCBS South Carolina | Trial and failure of preferred therapy |
| BCBS Tennessee | Step therapy required |
CareCost reads 27 payer policies for ocrelizumab. 8 of the 27 require a generic DMT first, quoted in full above. The remaining 19 — including UnitedHealthcare, Cigna, CareFirst and every BCBS plan not named in the table — do not name a required drug ahead of Ocrevus.
Every payer in this corpus that covers Ocrevus still requires the covered MS diagnosis and, at 23 of the 27, prior authorization on top of any DMT-first step; the generic-first requirement layers on top of those prerequisites, not in place of them.
Ocrelizumab’s label spans relapsing MS, active secondary progressive MS and primary progressive MS, and the clearance corpus files each under one of two lookup keys. Relapsing MS and active secondary progressive MS both use multiple_sclerosis; primary progressive MS uses its own key, primary_progressive_multiple_sclerosis, reviewed by all 27 payers separately from the relapsing-disease rules.
G35 is the category; it is not itself billable. The codes payers expect on the claim are the specific children below — G35.A for relapsing forms, G35.B1 for primary progressive and G35.C1 for active secondary progressive — and a claim coded only to the G35 family gets kicked back for the missing specificity.
| Indication | ICD-10 | dxKey |
|---|---|---|
| Relapsing forms of multiple sclerosis | G35.A | multiple_sclerosis |
| Primary progressive multiple sclerosis | G35.B1 | primary_progressive_multiple_sclerosis |
| Active secondary progressive multiple sclerosis | G35.C1 | multiple_sclerosis |
CareCost’s diagnosis picker above offers all three. Because relapsing and active secondary progressive disease share a dxKey, a payer’s rule for one applies to both; primary progressive MS is checked against its own set of 27 payer rules. The NLM Clinical Table Search Service confirmed these codes on 2026-09-21.
Original Medicare pays for Ocrevus as a Part B physician-administered drug, billed under J2350 alongside the administration codes below, once the claim documents a covered MS diagnosis and the labeled dose. There is no separate coverage-with-evidence-development registry requirement the way there is for some anti-amyloid Alzheimer's drugs; the standard Part B reasonable-and-necessary test applies.
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, including the generic-DMT-first and site-of-care rules some commercial plans in this corpus apply. Confirm that plan’s own policy instead of assuming Original Medicare’s rules carry over.
Ocrevus’s labeled 600 mg maintenance infusion runs 3.5 hours or longer, billed 96413 (initial hour, non-facility PFS $133.27) plus 96415 twice (each additional hour, $28.39 each). The label’s faster Option 2, about 2 hours and only after no prior serious infusion reaction, bills 96413 plus 96415 once. The two 300 mg initial infusions, each 2.5 hours or longer, also bill 96413 plus 96415 once. 96372 (therapeutic push) and 96365 (the therapeutic-infusion family some payers list separately) are the wrong code family for this chemotherapy/complex-biologic administration.
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 ocrelizumab policies CareCost has read require prior authorization before Ocrevus is covered. The other 4 apply the same clinical review without a formal prior-authorization label; the documentation burden is the same either way. Check this patient’s payer →
A covered MS diagnosis, the labeled dose and schedule, and at 8 of the 27 payers, a completed trial of a generic disease-modifying therapy first. Site of care and reauthorization timing add further requirements at some payers. Check this patient’s payer →
Yes, at 8 of the 27 payers in this corpus, and the drug required first is a generic disease-modifying therapy, not a preferred anti-CD20 antibody. BCBS Mississippi: “The individual has tried and failed (see definition of Medication Failure in Policy Guidelines section) ONE of the following generic agents” — failure of one generic disease-modifying therapy: dimethyl fumarate, fingolimod, glatiramer or teriflunomide. Regence: treatment with at least one low-cost DMT that was ineffective, not tolerated or contraindicated. Excellus: “The patient must have had serious side effects or drug failure of at least two medications…indicated for the treatment of multiple sclerosis (minimum 12-week trials).” Centene: “Failure of all of the following at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated” — dimethyl fumarate, teriflunomide, fingolimod, and an interferon-beta agent or glatiramer, for adults. Anthem, BCBS Kansas, BCBS South Carolina and BCBS Tennessee apply a similar trial-and-failure or step-therapy requirement. Check this patient’s payer →
No. Primary progressive MS carries its own clearance key, held by all 27 payers in this corpus, separate from the key that covers relapsing and active secondary progressive disease. Ocrevus is the only anti-CD20 antibody labeled for primary progressive MS, which is one reason payers track it as its own policy set. See the diagnosis coding detail →
11 of the 251 rules in this corpus touch where the infusion happens, at 10 different payers. Aetna: “Site of Care Utilization Management Policy applies for Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, and Tysabri.” Blue Shield of California names its preferred settings: “the home, a physician’s office, or an independent infusion center.” Florida Blue adds requirements specifically for “a hospital-affiliated outpatient setting.” Check this patient’s payer →
It runs on a 12-month calendar at the payers that state a term. BCBS Mississippi: “Length of Approval: 12 months.” Capital BlueCross: “Prior authorization validity may be renewed every 12 months thereafter.” BCBS Tennessee and Centene both renew on documented clinical response or disease stability rather than a fixed re-test. Check this patient’s payer →
Yes, at the two payers in this corpus that write a rule specific to that age group. Centene requires failure of fingolimod first for relapsing-remitting MS in patients 10 to 17: “Failure of fingolimod (Gilenya), unless contraindicated or clinically significant adverse effects are experienced.” Excellus requires serious side effects or drug failure of fingolimod for the same pediatric population. The label itself sets a separate dosing schedule below 35 kg. Check this patient’s payer →
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.