What do I do if my new insurance won't approve Rituxan or Ocrevus?

AnswerHere is my question:
What do I do if my new insurance won't approve Rituxan or Ocrevus? I've been on Rituxan for 3 years and I am doing well on MRI. I am losing my insurance because I am quitting my job. It is just too much for me to work anymore (I only work a couple of hours per week, so I cannot reduce more than that). I am going on my spouse's health insurance plan, but that plan plainly states it will not cover Ocrevus. It will only cover Rituxan after failing two other drugs first. I am afraid of what failure looks like with the amount of lesions and locations of them. What would you prescribe your patients? What do I do?

Answer:
It is hard to completely answer your question without knowing a little more about your condition. First of all, if you have progressive MS there are no other drugs approved other than anti CD20 agents such as Ocrevus or rituximab. Therefore, insurance really can not deny coverage in this circumstance unless you are too disabled (wheelchair bound) or too old (over 65). 

If you have relapsing MS, use of the anti-CD20 agents is discretionary by insurance companies. Here are my thoughts in this situation:

First things first: if you've been receiving rituximab every 6 months for 3 years, it is likely that the benefits of this treatment will last for several years without requiring any further treatments. There is no evidence that either rituximab or Ocrelizumab needs to be administered every 6 months indefinitely. In fact there is good evidence that the effect of a single treatment lasts more than a year. This means you can relax for the time being.

What you need to do is get your neurologist to monitor your condition with yearly MRIs and regular visits to determine if there is any evidence of worsening function.

Your neurologist can also monitor your CD19 blood counts. This will determine when the effects of rituximab are wearing off. Normally, your CD19 count is approximately 10 to 15 % of your total lymphocyte count. Following a single infusion of rituximab or Ocrelizumab at standard doses, CD19 counts in the blood remain very low or undetectable for 6 to 18 months. After repeated infusions of rituximab every 6 months (for 3 years in your case) the counts will sometimes remain low for more than 18 months. Since the main effect of rituximab is to deplete (kill off) the CD19 positive lymphocytes in your blood stream, this is a pretty good marker of drug effect. Interestingly, in MS patients the activity of your MS does not tend to return when the CD19 count normalize in your blood stream. This may be a result of prolonged beneficial effects of treatment on immune regulation.

If you do need another treatment with rituximab anytime soon, we can provide your doctor with a draft letter of medical necessity that is often helpful during peer to peer negotiations.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego