By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (cenegermin) Covered by Aetna CVS Health in Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Oxervate Covered by Aetna CVS Health in Texas

Oxervate (cenegermin) is covered by Aetna CVS Health as a non-preferred specialty drug requiring prior authorization and step therapy. For Stage 2-3 neurotrophic keratitis patients ≥2 years old, you'll need documented failure of preservative-free artificial tears and corneal sensitivity testing. Submit PA through CVS Caremark portal with ophthalmologist documentation. If denied, Texas offers strong appeal rights including Independent Review Organization (IRO) external review. Start today: Gather your eye exam notes, treatment history, and contact your ophthalmologist to begin the prior authorization process.

Table of Contents

Plan Types & Coverage Implications

Important update: Aetna exited the Texas individual marketplace for 2026, meaning new HMO, PPO, and EPO enrollments aren't available. However, existing members and employer-sponsored plans continue coverage.

For current Aetna members in Texas, plan type affects your path to Oxervate approval:

Plan Type Ophthalmologist Access Network Requirements Impact on Oxervate
HMO Referral from PCP required In-network only Must use in-network ophthalmologist for PA
PPO Direct access, no referral In- and out-of-network Can see any ophthalmologist; in-network preferred for lower costs
EPO Varies by specific plan In-network only Check if your plan requires referrals
Note: All plan types follow the same Oxervate coverage criteria, but HMO members need a primary care referral before seeing an ophthalmologist for the required diagnosis and documentation.

Formulary Status & Tier Placement

Oxervate (cenegermin) appears on Aetna's 2024 formularies as a non-preferred specialty pharmacy (NPSP) drug, placing it in the highest cost-sharing tier.

Coverage Details at a Glance

Requirement Details Documentation Needed
Formulary Status Specialty tier (NPSP); highest copay tier Verify via Aetna Drug Finder
Prior Authorization Mandatory for all plans Clinical notes, ICD-10 H16.239, ophthalmologist prescription
Step Therapy Must fail ≥2 preservative-free artificial tears (≥14 days each) Treatment dates, product names, response documentation
Age Restriction Patient must be ≥2 years old Date of birth verification
Prescriber Limitation Ophthalmologist required Provider credentials and specialty verification

The drug isn't excluded from standard Aetna plans, but the specialty tier designation means you'll face the highest copayment or coinsurance once your deductible is met.

Prior Authorization Requirements

Aetna requires comprehensive documentation proving medical necessity for Stage 2 or Stage 3 neurotrophic keratitis.

Medical Necessity Criteria

Your ophthalmologist must document all of the following:

Diagnosis Requirements:

  • Persistent epithelial defects (Stage 2) or corneal ulceration (Stage 3) lasting at least 2 weeks
  • ICD-10 code H16.239 (Other keratitis, unspecified eye)
  • Documented corneal sensitivity loss using cotton swab, Cochet-Bonnet aesthesiometer, or similar testing

Treatment History:

  • Failed trial of one or more preservative-free artificial tears for minimum 14 days each
  • Documentation of specific products tried, dates, and inadequate response
  • May include trials of ointments, punctal plugs, or bandage contact lenses

Clinical Documentation:

  • Comprehensive eye examination notes
  • Fluorescein staining results showing persistent defect or ulceration
  • Corneal sensitivity testing results (within and outside affected area)
  • Medical necessity letter explaining why Oxervate is appropriate

Submission Process

Timeline: Standard review takes 30-45 days; expedited review available in 72 hours for urgent cases.

How to Submit: Ophthalmologists can submit through the CVS Caremark provider portal or by fax. Mark requests as expedited if there's corneal risk or vision threat.

Step-by-Step: Fastest Path to Approval

1. Confirm Eligibility (Patient + Clinic)

What: Verify Aetna coverage and gather insurance information Documents: Insurance card, member ID, policy details Timeline: Same day Action: Call Aetna member services or check online portal

2. Ophthalmologist Evaluation (Clinic)

What: Complete comprehensive eye exam with required documentation Documents: Exam notes, corneal sensitivity testing, fluorescein staining, staging Timeline: 1-2 visits Action: Schedule with in-network ophthalmologist (referral required for HMO)

3. Document Step Therapy (Patient + Clinic)

What: Gather evidence of failed artificial tear trials Documents: Treatment dates, specific products, response notes, follow-up visits Timeline: Review existing records Action: Request records from previous providers if needed

4. Submit Prior Authorization (Clinic)

What: Complete PA submission through CVS Caremark Documents: All clinical documentation, medical necessity letter Timeline: Submit within 1-2 business days of gathering documentation Action: Use provider portal; mark expedited if urgent

5. Track Authorization Status (Patient + Clinic)

What: Monitor PA decision and respond to requests for additional information Timeline: Check every 3-5 business days Action: Log into CVS Caremark portal or call provider services

6. Enroll with Specialty Pharmacy (Patient)

What: Set up prescription fulfillment once approved Timeline: 1-2 business days after approval Action: CVS Specialty will contact you, or call them directly

7. Appeal if Denied (Patient + Clinic)

What: File internal appeal within 180 days if PA is denied Timeline: Begin immediately upon denial Action: Follow Texas appeals process outlined below

Specialty Pharmacy Requirements

Aetna routes Oxervate through CVS Specialty Pharmacy for most members, though some may use Accredo depending on their specific plan.

Patient Enrollment Process

Initial Setup: After PA approval, CVS Specialty's Care Team contacts you to:

  • Verify insurance benefits and copay responsibilities
  • Schedule delivery (weekly shipments of 7 vials, shipped frozen)
  • Provide storage and administration education
  • Set up 24/7 pharmacist support access

Delivery Details: Oxervate requires frozen storage until use. Each weekly kit contains 7 single-use vials. Patients thaw one vial at a time (up to 30 minutes at room temperature) for the 6-times-daily dosing.

Prescription Transfers: If your prescription was originally sent elsewhere, CVS Specialty can often transfer it automatically once the PA is approved.

Tip: Enroll in CVS Specialty's patient app for delivery tracking, medication reminders, and direct access to your care team.

Appeals Process in Texas

Texas provides robust appeal rights for insurance denials, including access to independent external review.

Internal Appeals (Required First Step)

Level 1 Appeal:

  • Deadline: 180 days from denial notice date
  • Decision Timeline: 30 days for pre-service requests, 60 days for post-service claims
  • Expedited: 72 hours if delay would jeopardize health

Level 2 Appeal:

  • Deadline: 60 days from Level 1 decision
  • Timeline: Same as Level 1

Texas Independent Review Organization (IRO)

If internal appeals are exhausted, Texas offers binding external review through an Independent Review Organization.

Eligibility:

  • Medical necessity or experimental/investigational denials
  • Financial responsibility exceeds $500
  • Must complete internal appeals first (except certain prescription drug cases)

Timeline:

  • Standard cases: 20 days
  • Urgent cases: 3-5 days
  • Filing deadline: 4 months from final internal denial

How to File: Complete Texas Department of Insurance LHL009 form and submit to Aetna with supporting documentation.

Important: The IRO decision is binding on Aetna. If they overturn the denial, Aetna must cover Oxervate.

Texas Resources for Help

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO Information Line: 1-866-554-4926

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Incomplete step therapy Document specific artificial tear trials with dates and outcomes Treatment logs, pharmacy records, provider notes
Inadequate staging documentation Provide detailed ophthalmologic exam with fluorescein staining Exam photos, staining results, staging criteria
Missing corneal sensitivity testing Submit sensitivity test results from multiple corneal quadrants Aesthesiometer results, cotton swab testing documentation
Non-formulary status Request formulary exception with medical necessity justification Comparative effectiveness data, contraindications to alternatives
Prescriber not qualified Ensure prescription comes from ophthalmologist Provider credentials, specialty board certification

From Our Advocates

In our experience helping patients navigate specialty drug appeals, the strongest cases include a clear timeline showing the progression from initial conservative treatment through step therapy failures to the current medical necessity for Oxervate. Documentation that tells the complete clinical story—not just isolated test results—tends to be most persuasive to reviewers.

Cost-Share and Financial Assistance

As a specialty tier medication, Oxervate typically requires significant cost-sharing even after PA approval.

Typical Cost Structure

  • Deductible: Must be met before insurance coverage begins
  • Coinsurance: Usually 25-50% of drug cost for specialty tier
  • Out-of-pocket maximum: Coverage at 100% once annual limit is reached

Financial Assistance Options

Manufacturer Support: Dompé CONNECT to Care offers:

  • Copay assistance (potentially reducing costs to $100 for commercial insurance)
  • Patient assistance programs for uninsured/underinsured patients
  • Prior authorization support services

Additional Resources: Contact your ophthalmologist's office about patient assistance foundations that may provide grants for rare disease medications.

FAQ

How long does Aetna CVS Health prior authorization take for Oxervate in Texas? Standard PA decisions take 30-45 days. Expedited reviews are available in 72 hours if your ophthalmologist certifies that delay would jeopardize your health or vision.

What if Oxervate is denied as non-formulary? You can request a formulary exception by providing medical necessity documentation and evidence that formulary alternatives are inappropriate or contraindicated for your condition.

Can I request an expedited appeal in Texas? Yes. Expedited appeals are available when standard timelines would seriously jeopardize your health. Your ophthalmologist must certify the urgency in writing.

Does step therapy apply if I tried artificial tears in another state? Yes, step therapy documentation from any provider is acceptable as long as it includes specific products, dates, duration, and treatment response.

What happens if my 8-week Oxervate course doesn't fully heal my cornea? Some patients may need re-treatment. Your ophthalmologist can submit a new PA request with documentation of partial response and medical justification for additional therapy.

How do I know if my Aetna plan covers specialty drugs? Check your Summary of Benefits and Coverage (SBC) or call the member services number on your insurance card. Most Aetna plans cover specialty drugs but place them in the highest cost-sharing tier.

When Treatment is Denied: Advanced Appeal Strategies

If standard appeals don't succeed, consider these escalation options:

Peer-to-Peer Review: Request that your ophthalmologist speak directly with Aetna's medical director to discuss your case.

State Insurance Commissioner Complaint: File a complaint with the Texas Department of Insurance if you believe Aetna isn't following proper procedures.

Congressional Inquiry: Contact your U.S. Representative or Senator's office if you're facing life-threatening delays in coverage decisions.

When navigating complex prior authorization requirements and appeals, many patients and providers find value in specialized support. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific rules and requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and doesn't constitute medical or legal advice. Coverage policies and appeal procedures may vary by specific plan and can change. Always verify current requirements with your insurance company and consult with your healthcare provider about treatment decisions. For personalized assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.