Multiple Sclerosis (CPB 0264, reviewed 2026-08-05)

IMMEDIATELY: Billing and clinical teams must implement the following: (1) Update authorization workflows to require precertification for Briumvi, Lemtrada, Ocrevus, Ocrevus Zunovo, Tyruko, and Tysabri by calling (866) 752-7021 or faxing (888) 267-3277 before claim submission. (2) Providers must document that medications are prescribed by or in consultation with a neurologist for Lemtrada, Briumvi, Ocrevus/Ocrevus Zunovo, and mitoxantrone—claims lacking this documentation will be denied. (3) Implement system checks to flag claims when patients receive multiple disease-modifying MS agents concurrently (note: Ampyra and Nuedexta are exceptions and may be combined). (4) For all new MS medication requests, verify clinical criteria are met: for Lemtrada—documented inadequate response to 2+ MS drugs or completion of prior course with 12-month interval; for Ocrevus/Briumvi—confirmation of relapsing forms, CIS, or PPMS (as applicable) with documented disease stability/improvement for continuation. (5) Update encounter templates to capture required medical necessity documentation. (6) Training required for billing, pre-auth, and clinical staff on new precertification process. Failure to obtain precertification will result in claim denials; failure to document neurologist involvement will result in coverage denials.