Navigating Medicaid coverage for specialty treatments like Ocrevus (ocrelizumab) can feel overwhelming. However, this benefit is available to over 90% of Medicaid enrollees with Multiple Sclerosis.
Medicaid is run by individual states. As a result, the exact process varies. Here is a clear breakdown of how the payment and approval process typically works.
1. The Approval Process: Medical Necessity
Medicaid usually treats Ocrevus as a medical benefit. It is not treated as a standard pharmacy benefit. This is because it is administered by a healthcare professional via infusion. To get it paid for, your doctor must prove it is “medically necessary.”
- Prior Authorization (PA): Your neurologist must submit a request to Medicaid before you start treatment. They will need to provide your MS diagnosis (Relapsing MS or Primary Progressive MS) and MRI results.
- Step Therapy: Some states require “Step Therapy.” This means you may need to try and fail one or two other “preferred” MS medications. These can include options like interferons or glatiramer acetate. This must occur before Medicaid will pay for Ocrevus.
- Specialist Requirement: In almost all cases, the prescription must come from a neurologist. Alternatively, an MS specialist’s prescription is required for eligibility for coverage.
2. What Does Medicaid Pay For?
When Ocrevus is approved, Medicaid typically covers two distinct costs:
- The Medication: The actual cost of the Ocrevus vials.
- The Administration: The cost of the infusion center, the nursing staff, and the IV supplies used during your appointment.
Out-of-Pocket Costs: For most Medicaid clients, the out-of-pocket cost is $0. Alternatively, there is a very small nominal co-pay, usually between $1 and $4. This depends on your state’s specific rules.
3. If You Are Denied or Have High Costs
If Medicaid denies the initial request or if you have a “spend-down” (a deductible-like amount you must pay before Medicaid kicks in), there are backup options:
- The Genentech Patient Foundation: The manufacturer of Ocrevus offers a program for people with “public insurance,” such as Medicaid. This program assists those who still face financial barriers. If you meet their income criteria, they may provide the medicine free of charge.
- The PAN Foundation: This is a charitable organization. It provides grants specifically for MS patients on government insurance. These grants help cover any remaining costs or co-pays.