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HealthPartners

Coverage criteria policies

Ocrelizumab (Ocrevus)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

  • Prior authorization is required for ocrelizumab (Ocrevus).

Coverage

  • Ocrelizumab (Ocrevus) is generally covered1 subject to the indications listed below and per your plan documents.

Indications that are covered

For adults 18 years or older with Relapsing-remitting Multiple Sclerosis:

  1. Patient with diagnosis of relapsing-remitting multiple sclerosis (RRMS); and;
  2. Patient has documented treatment failure on any one of the following preferred agents: Copaxone 40mg, Gilenya, Tecfidera, Aubagio, Avonex, Plegridy, Rebif, Extavia, Glatopa; and,
  3. Patient is not receiving ocrelizumab in combination with another disease modifying agent (e.g., interferon beta preparations, glatiramer acetate, dimethyl fumarate); and,
  4. The prescribed regimen is consistent with the FDA approved dosing regimen and,
  5. Patient meets Site of Care criteria below - For commercial products only (does not apply to Medicare or Minnesota Health Care Programs products).
  6. Authorization will be provided for 12 months.
  7. Reauthorization will be provided for members with stable disease meeting initial authorization criteria. Reauthorization will be provided for 12 months.

For adults 18 years or older with Primary Progressive Multiple Sclerosis:

  1. Patient with diagnosis of primary progressive multiple sclerosis (PPMS) and;
  2. 2 of the 3 following criteria: 
    1. Evidence of dissemination of lesions in space (DIS) in the brain based on ≥1 T2 lesions in at least 1 area characteristic for MS (juxtacortical, infratentorial, or periventricular)
    2. Evidence for DIS in the spinal cord based on ≥2 T2 lesions in the cord
    3. Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index ).
  3. The prescribed regimen is consistent with the FDA approved dosing regimen and,
  4. Patient meets Site of Care criteria below - For commercial products only (does not apply to Medicare or Minnesota Health Care Programs products).
  5. Authorization will be provided for 6 months.
  6. Reauthorization will be provided for members with stable disease meeting criteria 1, 3, and 4 above. Reauthorization will be provided for 12 months.

Site of Care:

  1. For commercial products only (does not apply to Medicare or Minnesota Health Care Programs products), medication administration must occur at a clinic office or home-infusion setting unless medical necessity is met based on the criteria below, supported by medical documentation:
  2. The patient has experienced a severe or life-threatening reaction with previous infusions of the same or similar products; or,
  3. The patient has a medical condition that renders him or her unstable, exceptionally complex, immunocompromised or otherwise high-risk such that continued oversight in the current facility is required; or,
  4. There are no alternative settings available to the patient as a result of both of the following:
    1. The patient is unable to use home-infusion services as documented by the physician, social worker, or infusion provider; and,
    2. The patient is unable to access alternative settings due to unreasonable distance [>30 miles] or other extenuating circumstances.

Indications that are not covered

  • Ocrelizumab (Ocrevus) is not covered for any additional indication.

Definitions

OCREVUS is a CD20-directed cytolytic antibody indicated for the treatment of patients with relapsing or primary progressive forms of multiple sclerosis (1)

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:
HCPCS

Codes

Description

C9399

Unclassified drugs or biologicals

J3590

Unclassified biologics

NDC

Codes

Description

50242015001

Ocrevus 300mg/10ml vial

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Ocrevus [Prescribing Information]. Genentech, Inc.: San Francisco, CA. March 2017.

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Policy activity

  • 09/01/2017 - Date of origin
  • 09/01/2017 - Effective date
Revision date
  • 09/01/2017

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