Ocrevus Health Insurance Denial

• Received an Ocrevus Health Insurance Denial? Contact Us
• What is Ocrevus?
• How Is Ocrevus Administered?
• How Much Does Ocrevus Cost? 
• Is There a Biosimilar or Generic for Ocrevus? 
• Do Insurance Companies Cover Ocrevus as a Treatment for Multiple Sclerosis?
• Medically Necessary, Medically Beneficial, Experimental, or Investigational – Knowing the Terms and Their Meaning
• What Duty Do Insurance Companies Have to Members Submitting Claims?
• Contact the Law Offices of Scott Glovsky if You Receive an Ocrevus Health Insurance Denial 

Ocrevus is a drug used for relapsing and primary progressive forms of multiple sclerosis. The FDA granted priority review to Genentech for an Ocrevus (ocrelizumab) Biologics License. The review of the application was extended in December 2016, with the FDA granting approval for Ocrevus on March 28, 2017. In June 2017, new data showed that Ocrevus significantly reduced disease progression for relapsing and primary progressive multiple sclerosis.

In December 2020, the FDA approved the shorter two-hour infusion of Ocrevus. This article addresses Ocrevus health insurance coverage claims, as well as details about how insurance companies make decisions regarding medical necessity. It also covers the necessary steps to take after receiving an Ocrevus health insurance denial. If your insurance company has denied your claim for Ocrevus, contact the Law Offices of Scott Glovsky.

What is Ocrevus?

Ocrevus is a humanized monoclonal antibody designed to selectively target CD20-positive B cells. These are a specific type of immune cell, thought to be a key contributor to myelin and axonal nerve cell damage. These B cells, which contribute to the immune system’s attack on the central nervous system in multiple sclerosis, are depleted by Ocrevus. This lessens inflammation and damage to the myelin sheath (the protective coating around nerve fibers), slowing the progression of relapsing and primary progressive forms of MS.

How Is Ocrevus Administered?

Ocrevus is administered as an intravenous infusion into a vein in the arm, typically by a healthcare professional in a clinic, infusion center, or at home. The first dose is split into two separate infusions, two weeks apart. Each initial infusion lasts about 2.5 hours. Subsequent treatments are administered as a single infusion every six months. You can obtain more information about Ocrevus here.

How Much Does Ocrevus Cost? 

As of July 2025, the list price of Ocrevus is $78,858 annually. Those with insurance will pay anywhere from $0 to around $15,000 per year, depending on the insurer. The Ocrevus Co-Pay Program offers up to $1,500 in assistance for the first year, and $1,000 annually thereafter, with no income limits. Medicare costs can range from $0 to $15,772, while Medicaid costs are typically minimal but depend on income and state regulations.

Is There a Biosimilar or Generic for Ocrevus? 

Biosimilar drugs are the generic counterpart to brand biologic drugs. While there are currently no approved, commercially available biosimilars for Ocrevus, several are in development, including Xacrel, which demonstrated comparable safety and efficacy to Ocrevus in a Phase II trial. Another biosimilar drug for MS, CT-P53, is also in a phase III trial.

The original patent for Ocrevus is set to expire in 2029 in the United States and in 2028 in Europe, which will open the door for more biosimilar drugs to enter the market. Biosimilar drug development can be a lengthy process with varying approval timelines.

Do Insurance Companies Cover Ocrevus as a Treatment for Multiple Sclerosis?

Ocrevus may be partially covered by Medicare, a health insurance program for individuals aged 65 and older. Medicare coverage may come through a Medicare Advantage Plan (Part C) or a Supplemental Medicare Plan (Part D). Patients are required to enroll separately for this prescription coverage. For low-income patients, Medicaid will likely cover Ocrevus, although prior authorization may be required. Commercial private insurance companies like Blue Shield, Kaiser Permanente, Healthnet, Medi-Cal Managed Care Plans, UnitedHealthcare, Anthem, and Aetna will have different coverage standards.

You have the right to appeal an Ocrevus health insurance denial, but the manner in which you appeal the denial will be determined based on whether you have an ERISA (Employment Retirement Income Security Act of 1974) or non-ERISA plan. Most private employers offer ERISA plans, except for business plans that only cover business owners, individual and family plans through Covered California, religious organization plans, government employee plans, and individual or family plans purchased through private insurance companies, such as Blue Shield of California or Anthem Blue.

Medically Necessary, Medically Beneficial, Experimental, or Investigational – Knowing the Terms and Their Meaning

 Before an insurer will pay for an expensive drug, prior authorization is typically required. Prior authorization requires your insurer to make a decision regarding whether it believes the drug is medically necessary for you and your specific health condition. An insurer may deem a drug not medically necessary when a cheaper alternative exists, or may require step therapy.

Step therapy requires the patient to try alternative (usually less expensive) drugs before the company will re-evaluate the original claim. Typically, patients must try at least two alternative drugs for 60 days each. In some cases, exemptions from step therapy are available in California, but the process can be complex.

When an insurer says that a drug is not medically necessary, it may also consider it experimental or investigational. The policy definitions of "experimental" and "investigational" are determined by pharmacists and other medical practitioners employed by the company who develop internal clinical policies. Once the policies are developed, a group of external doctors votes on the policies.

Unfortunately, these doctors may have been given financial incentives or promises of jobs with the company, which can affect their objectivity. Essentially, it’s possible that the doctors may recommend that the company deny claims for more expensive drugs as a quid pro quo.

A drug may also be labeled experimental or investigational when a doctor prescribes the drug off-label. Off-label prescriptions occur when a drug is prescribed for a condition not approved by the FDA, prescribed in a different dosage, or prescribed for a different age group than approved for. Off-label prescribing occurs every single day, with some estimates as high as 45 percent for off-label prescribing.

What Duty Do Insurance Companies Have to Members Submitting Claims?

When a member submits a claim, the insurance company reviews the claim and makes a decision to approve or deny it. The insurer has a duty to:

• Thoroughly investigate the claim request
• Fully inquire into all potential reasons that would support the request.
• Promptly respond to claim requests
• Appoint and employ qualified medical professionals to make claim review decisions.

If a claim passes the initial review, the insurer may deny it following a more thorough review. A denial could be due to policy exclusions, lack of medical necessity, missed deadlines, an out-of-network provider, coding errors, lack of prior authorization, or the fact that the drug is experimental or investigational.

Contact the Law Offices of Scott Glovsky if You Receive an Ocrevus Health Insurance Denial

If you have received an Ocrevus health insurance denial, your very best course of action is to speak to a strong legal advocate like Attorney Scott Glovsky. The Law Offices of Scott Glovsky has represented injured consumers and victims of wrongful business practices for more than 25 years. Our firm focuses on health insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related litigation. Attorney Glovsky and his legal team strive to secure justice for every client while holding the wrongdoers accountable.