Ocrevus Insurance Denial Appeal Guide

Ocrevus (ocrelizumab) is the first FDA-approved treatment for primary progressive MS and is also approved for relapsing MS. Insurance denials often involve step therapy or site of care restrictions.

Why Ocrevus Gets Denied

Ocrevus is one of the most expensive MS treatments at approximately $65,000/year. Insurers may require failure of oral DMTs or other infusion therapies first. Site of care restrictions (requiring specific infusion centers) also create access barriers.

Common Denial Reasons

  • Step therapy (must try oral DMTs like Tecfidera or Gilenya first)
  • Prior authorization missing or incomplete
  • For PPMS: insufficient documentation of progressive disability
  • Site of care restrictions
  • Dosing schedule or frequency questions

How to Appeal

  1. For PPMS — emphasize Ocrevus is the ONLY FDA-approved treatment for progressive MS
  2. For relapsing MS — document failures or intolerance of oral therapies
  3. Cite OPERA and ORATORIO trials — strong efficacy data
  4. Neurologist letter — MS specialists carry significant weight in appeals
  5. Document MRI evidence — active lesions, brain volume loss, disability progression

PPMS-Specific Appeal

For primary progressive MS, there is no step therapy argument — Ocrevus is the only approved therapy. Any denial for PPMS should be appealed aggressively on this basis.

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Frequently Asked Questions

Is Ocrevus the only treatment for progressive MS?

Yes, Ocrevus is currently the only FDA-approved disease-modifying therapy for primary progressive MS. This makes step therapy requirements particularly unreasonable for PPMS patients.

How is Ocrevus administered?

Ocrevus is given as an IV infusion every 6 months. The first dose is split into two infusions given 2 weeks apart.

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