By Counterforce Health Team in Oxervate (cenegermin) —

Get Oxervate (Cenegermin) Covered by Blue Cross Blue Shield Michigan: Forms, Appeals & Prior Authorization Guide

Answer Box: Getting Oxervate Covered by BCBS Michigan

Blue Cross Blue Shield of Michigan requires prior authorization for Oxervate (cenegermin) to treat neurotrophic keratitis in patients 2+ years old. Fast track to approval: 1) Confirm stage 2/3 neurotrophic keratitis diagnosis with corneal sensitivity testing, 2) Document failed standard treatments (artificial tears, therapeutic contact lenses), 3) Submit PA request via BCBSM provider portal with complete clinical notes. Coverage limited to 8 kits per affected eye lifetime. If denied, you have 65 days for internal appeal, then 127 days for Michigan DIFS external review.

Table of Contents

Start Here: Verify Your Plan & Find Forms

Before requesting Oxervate coverage, confirm your specific Blue Cross Blue Shield of Michigan plan details. BCBSM covers approximately 67% of Michigan's commercial insurance market, but requirements vary by plan type.

Step 1: Verify Coverage

  • Check your member ID card for the customer service number
  • Call 1-888-288-2738 for individual plans
  • Confirm Oxervate is on your plan's formulary and requires prior authorization

Step 2: Locate Current Forms Access the most current prior authorization forms through the BCBSM provider portal or request from your ophthalmologist's office.

Note: BCBSM policies are updated regularly. Always verify you're using the current year's forms and criteria.

Prior Authorization Forms & Requirements

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all members BCBSM Drug List
Age Limit 2 years or older BCBSM Policy
Diagnosis Confirmed neurotrophic keratitis (stage 2/3) BCBSM Policy
Quantity Limit 8 kits per affected eye (lifetime) BCBSM Policy
Renewal Generally no renewal per treated eye BCBSM Policy

Required Documentation Checklist

Clinical Information:

  • Confirmed diagnosis of neurotrophic keratitis with staging (Mackie Classification)
  • Corneal sensitivity testing results (Cochet-Bonnet esthesiometer ≤4 cm in ≥1 quadrant)
  • Slit lamp examination findings with fluorescein staining
  • Duration of persistent epithelial defect (>2 weeks for stage 2)
  • Visual acuity measurements (BCDVA)

Prior Treatment Documentation:

  • Failed preservative-free artificial tears (minimum 2 weeks)
  • Therapeutic contact lens trial results (if applicable)
  • Antibiotic drop history for secondary infection
  • Any surgical interventions attempted (tarsorrhaphy, amniotic membrane)

Submission Portals & Electronic Filing

BCBSM Provider Portal Access

Healthcare providers submit Oxervate prior authorization requests through the Availity portal system:

  1. Login to Availity: Visit availity.com
  2. Access BCBSM: Click "Payer Spaces," select BCBSM logo
  3. Navigate to PA: Find "Medical and Pharmacy Benefit Drug Prior Auth" tile
  4. Complete Request: Enter member details, select Oxervate, attach clinical documentation
Tip: Upload all supporting documents before completing the drug questionnaire to ensure complete submission.

Patient Portal Options

Members can track prior authorization status through:

  • BCBSM member portal (login required)
  • Mobile app for status updates
  • Customer service line on member ID card

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Essentials

Problem Statement:

  • Specific neurotrophic keratitis stage (2 or 3) with Mackie classification
  • Underlying etiology (diabetes, herpes simplex, surgical trauma, etc.)
  • Impact on vision and quality of life

Prior Treatment History:

  • Detailed timeline of conservative treatments attempted
  • Specific reasons for treatment failure or intolerance
  • Duration of each intervention with documented outcomes

Clinical Rationale:

  • Why Oxervate is medically necessary for this patient
  • Expected treatment outcomes and monitoring plan
  • Reference to FDA labeling for neurotrophic keratitis

Dosing and Administration:

  • Confirm 1 drop to affected eye(s) 6 times daily for 8 weeks
  • Patient/caregiver counseling on proper administration technique
  • Contact lens removal requirements (15-minute wait before reinsertion)

Appeals Process for BCBS Michigan

Internal Appeals Timeline

Appeal Level Deadline to File BCBSM Response Time How to Submit
Internal Appeal 65 days from denial 7 days (standard) / 72 hours (expedited) Provider portal or written request
Peer-to-Peer Review During internal appeal 72 hours to schedule Request via customer service

Step-by-Step Internal Appeal Process

1. Gather Documentation (Day 1-3)

  • Original denial letter with specific reason codes
  • Additional clinical evidence addressing denial reasons
  • Updated medical necessity letter from ophthalmologist

2. Submit Internal Appeal (Day 4-7)

  • Use BCBSM provider portal or mail written appeal
  • Include all supporting documentation
  • Request expedited review if clinically urgent

3. Prepare for Peer-to-Peer (if offered)

  • Schedule within 72 hours of request
  • Have clinical data readily available
  • Focus on medical necessity and failed alternatives
From our advocates: We've seen BCBS Michigan approvals increase significantly when providers include detailed corneal sensitivity testing results and document specific treatment failures with dates and clinical outcomes. The key is matching your documentation exactly to their published criteria.

Specialty Pharmacy & Transfer Instructions

BCBSM Preferred Specialty Pharmacies

Oxervate requires specialty pharmacy dispensing due to its unique storage and handling requirements:

Transfer Process:

  1. Prescription Routing: Your ophthalmologist sends the prescription to a BCBSM-contracted specialty pharmacy
  2. Prior Authorization Link: Pharmacy coordinates with PA approval status
  3. Patient Onboarding: Specialty pharmacy contacts you for delivery scheduling and administration training
  4. Cold Chain Delivery: Oxervate requires refrigerated shipping and proper storage

Expected Timeline:

  • PA approval to first dose: 3-5 business days
  • Ongoing refills: 48-72 hours notice recommended

Support Lines & Case Management

Key Contact Numbers

Member Services:

  • Individual plans: 1-888-288-2738
  • Employer plans: Number on member ID card
  • Medicare Plus Blue: 1-877-469-2583

Provider Services:

  • Prior authorization status: 1-313-225-9000
  • Pharmacy benefits: Use provider portal for fastest response

What to Ask When Calling:

  • Current PA status and any missing documentation
  • Expected decision timeline
  • Appeal rights if denied
  • Case management assignment for complex cases

Michigan External Review Process

If BCBS Michigan denies your internal appeal, Michigan law provides additional protection through the Department of Insurance and Financial Services (DIFS).

Timeline and Process

Filing Deadline: 127 days from final internal denial Standard Review: Up to 60 days for decision Expedited Review: 72 hours (requires physician letter stating delay would harm patient)

How to File External Review

Online: Use DIFS External Review Request form Phone: 877-999-6442 Email: [email protected]

Required Documents:

  • Copy of original denial letter
  • Final internal appeal denial
  • All supporting medical records
  • Physician statement of medical necessity
Important: DIFS external review decisions are binding on your insurer. Independent medical experts will evaluate whether Oxervate is medically necessary for your specific condition.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient diagnosis documentation Provide detailed staging with Mackie classification Slit lamp exam, fluorescein staining, corneal sensitivity testing
Inadequate prior therapy trials Document specific treatment failures with dates Treatment timeline with outcomes, reasons for discontinuation
Age requirement not met Confirm patient is 2+ years old Birth date verification, pediatric ophthalmology consultation if needed
Quantity limit exceeded Justify additional kits for new diagnosis or different eye New clinical assessment, separate eye documentation
"Not medically necessary" Strengthen clinical rationale with guidelines FDA labeling, peer-reviewed studies, specialty society recommendations

Scripts for Common Situations

Patient Phone Script for BCBS Michigan: "Hello, I'm calling about prior authorization status for Oxervate prescription for neurotrophic keratitis. My member ID is [number]. Can you tell me the current status and if any additional documentation is needed?"

Clinic Staff Peer-to-Peer Request: "I'd like to request a peer-to-peer review for Oxervate prior authorization denial. The patient has stage 3 neurotrophic keratitis with documented treatment failures. When can we schedule the clinical review?"

FAQ

Q: How long does BCBS Michigan prior authorization take for Oxervate? A: Standard PA decisions are made within 7 days. Expedited requests (when clinically urgent) are decided within 72 hours.

Q: What if Oxervate isn't on my BCBS Michigan formulary? A: Submit a formulary exception request with your PA, demonstrating medical necessity and lack of suitable alternatives.

Q: Can I get an expedited appeal for Oxervate denial? A: Yes, if your ophthalmologist documents that delay would seriously harm your vision or health. Expedited appeals are decided within 72 hours.

Q: Does step therapy apply to Oxervate in Michigan? A: Yes, BCBS Michigan typically requires documentation of failed conservative treatments before approving Oxervate.

Q: What's the lifetime limit for Oxervate coverage? A: BCBS Michigan covers up to 8 kits per affected eye over your lifetime. Each kit contains 7 multiple-dose vials.

Q: Can I use manufacturer assistance with BCBS Michigan coverage? A: Check with Dompé Farmaceutici's patient assistance program. Some programs can supplement insurance coverage for out-of-pocket costs.

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Oxervate. Our platform analyzes denial letters, identifies specific coverage criteria, and drafts evidence-backed appeals that address each payer's requirements. For patients and providers navigating BCBS Michigan's prior authorization process, having the right documentation and appeal strategy can make the difference between denial and approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with insurance appeals in Michigan, contact the Michigan Department of Insurance and Financial Services at 877-999-6442.

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