By Counterforce Health Team in Oxervate (cenegermin) —

Get Oxervate (cenegermin) Covered by Cigna in Florida: Complete Prior Authorization & Appeals Guide

Quick Answer: To get Oxervate (cenegermin) covered by Cigna in Florida, you'll need prior authorization through Express Scripts with documentation of stage 2 or 3 neurotrophic keratitis, failed conservative treatments (≥14 days artificial tears), and a medical necessity letter from your ophthalmologist. Submit via CoverMyMeds or Express Scripts portal. If denied, you have 180 days for internal appeals, then can request external review through Florida Department of Financial Services within 4 months.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Oxervate prescriptions Cigna PA Policy
Formulary Status Specialty tier, managed by Express Scripts Cigna member portal
Diagnosis Stage 2 or 3 neurotrophic keratitis ICD-10: H16.09, H18.89
Prescriber Ophthalmologist or optometrist License verification required
Failed Treatments ≥14 days preservative-free artificial tears Chart documentation needed
Age Requirement ≥2 years Medical records
Duration 8 weeks initial approval No refills without reauthorization

Set Your Goal: Understanding Cigna's Requirements

Getting Oxervate (cenegermin) approved by Cigna requires a partnership between you and your eye doctor. This FDA-approved treatment for neurotrophic keratitis costs upwards of $100,000 for an 8-week course, making prior authorization essential.

Your goal is straightforward: demonstrate that you have confirmed stage 2 or 3 neurotrophic keratitis that hasn't responded to standard treatments, and that Oxervate is medically necessary to prevent vision loss or corneal perforation.

Cigna manages specialty drugs like Oxervate through Express Scripts/Accredo specialty pharmacy, so your approval will come through their prior authorization process.

Visit Prep: Documenting Your Journey

Before your appointment, gather this timeline to help your doctor understand your case:

Symptom History

  • When did you first notice eye discomfort or vision changes?
  • How has your condition progressed?
  • What activities are now difficult (reading, driving, work)?

Treatment Timeline Create a chronological list of everything you've tried:

  • Preservative-free artificial tears (brands, frequency, duration)
  • Antibiotic drops or ointments
  • Bandage contact lenses
  • Punctal plugs
  • Any surgical procedures (tarsorrhaphy, amniotic membrane)

Document failures specifically: "Used Systane Ultra preservative-free 4x daily for 6 weeks in March-April 2024. Epithelial defect persisted despite compliance."

Evidence Kit: Building Your Case

Your ophthalmologist will need comprehensive documentation to support the prior authorization:

Diagnostic Evidence

  • Corneal sensitivity testing (Cochet-Bonnet esthesiometer results)
  • Slit-lamp examination photos with fluorescein staining
  • Staging documentation (Mackie classification: stage 2 = persistent epithelial defect; stage 3 = corneal ulcer)
  • Anterior segment OCT if available

Clinical History

  • Complete ophthalmology records
  • Previous treatment responses and failures
  • Any complications or risk factors
  • Current medications and allergies
From our advocates: We've seen cases where patients brought a simple timeline to their appointment—just dates and treatments on one page—and it made the difference in getting complete documentation for a successful prior authorization. The key is showing you've tried conservative measures first.

Medical Necessity Letter Structure

Your ophthalmologist's letter is crucial for approval. Here's what it should include:

Required Elements

  1. Patient identification: Full name, DOB, Cigna member ID
  2. Diagnosis: "Stage [2/3] neurotrophic keratitis confirmed by [specific findings]"
  3. Failed prior treatments: Detailed timeline with dates, durations, and outcomes
  4. Medical necessity: Why Oxervate is the appropriate next step
  5. Dosing: "1 drop 6 times daily to affected eye(s) for 8 weeks"
  6. Risk of delay: Potential for corneal perforation or permanent vision loss

Template Language "Patient has confirmed stage 2 neurotrophic keratitis with persistent epithelial defect measuring X mm, documented reduced corneal sensation (Cochet-Bonnet: X cm), and has failed adequate trials of preservative-free artificial tears for ≥14 days, [other treatments]. Oxervate (cenegermin) is the only FDA-approved treatment for this indication and is medically necessary to prevent progression to corneal perforation."

Peer-to-Peer Review Support

If Cigna requests a peer-to-peer review, your doctor will discuss your case directly with a Cigna medical reviewer. You can help by:

Offering Availability Let your doctor's office know your preferred times for scheduling the call (they may need you available for questions).

Case Summary Prepare a one-page summary including:

  • Current stage and symptoms
  • All failed treatments with specific dates
  • Risk factors for progression
  • Functional impact on daily life

Guidelines References Ask your doctor to reference the FDA approval data and any relevant ophthalmology society guidelines during the call.

After Your Visit: Next Steps

Document Everything

  • Save copies of all forms submitted
  • Get confirmation numbers for electronic submissions
  • Keep your doctor's notes and any test results

Track Your Submission

  • Check your Cigna member portal for status updates
  • Standard prior authorization decisions: 5-15 business days
  • Expedited reviews (for urgent cases): 72 hours

Stay Connected Message your doctor's office through their patient portal if you haven't heard back within the expected timeframe.

Appeals Playbook for Florida

If your initial prior authorization is denied, don't give up. Florida residents have strong appeal rights, and many denials are overturned with proper documentation.

Internal Appeals (Required First Step)

Level 1 Appeal

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Submit to: Address specified in your denial letter
  • Include: Denial letter, updated medical records, physician appeal letter

Level 2 Appeal

  • Deadline: 60 days from Level 1 denial
  • Timeline: 45-60 days for decision
  • Process: Independent clinical review by different Cigna reviewers

External Review (After Internal Appeals)

If Cigna upholds the denial, Florida residents can request an independent external review through the Florida Department of Financial Services.

Key Details

  • Deadline: 4 months from final internal denial
  • Cost: Free to consumers
  • Process: Independent medical expert reviews your case
  • Decision: Binding on Cigna if favorable
Tip: For urgent cases involving risk of corneal perforation, you can request expedited external review with a decision within 72 hours.

Common Denial Reasons & Solutions

Denial Reason How to Address
"Insufficient documentation of stage 2/3 NK" Submit corneal photos, sensitivity testing, staging notes
"Inadequate trial of conservative therapy" Provide detailed timeline showing ≥14 days of appropriate treatments
"Not medically necessary" Include peer-reviewed literature, FDA labeling, ophthalmology guidelines
"Step therapy not completed" Document contraindications or failures of required alternatives

Costs & Patient Support

Manufacturer Support Dompé offers the iAssist program providing:

  • Benefits verification
  • Prior authorization support
  • Appeal assistance
  • Potential copay assistance

Specialty Pharmacy Once approved, Oxervate is dispensed through Accredo specialty pharmacy, which provides:

  • Coordination with your insurance
  • Home delivery
  • Clinical support

For complex denials, services like Counterforce Health specialize in turning insurance denials into successful appeals by analyzing payer policies and crafting targeted rebuttals with the right clinical evidence and procedural requirements.

FAQ

How long does Cigna prior authorization take in Florida? Standard reviews take 5-15 business days. Urgent cases with risk of serious harm can be expedited to 72 hours with proper physician documentation.

What if Oxervate is non-formulary on my plan? You can request a formulary exception through Cigna's standard process. Your doctor must demonstrate medical necessity and that formulary alternatives are inappropriate.

Can I appeal if I'm in a Cigna Medicare Advantage plan? Yes, but the process differs. Medicare Advantage appeals follow federal timelines and may go to an independent review entity rather than Florida's external review process.

What counts as "failed conservative therapy"? Cigna typically requires at least 14 days of preservative-free artificial tears plus documentation of other appropriate treatments like antibiotic drops, bandage lenses, or punctal plugs.

Do I need to see a cornea specialist? While any ophthalmologist can prescribe Oxervate, cornea specialists often have more experience with the prior authorization process and may have better success rates.

What if my appeal is denied? After exhausting internal appeals, Florida residents can request external review through the Department of Financial Services. You can also file a complaint with the Florida Office of Insurance Regulation.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific situation. For assistance with insurance issues in Florida, contact the Department of Financial Services Consumer Helpline at 1-877-MY-FL-CFO (1-877-693-5236).

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