By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization Guide

Answer Box: Getting Oxervate Covered by Blue Cross Blue Shield in Washington

Blue Cross Blue Shield plans in Washington typically require prior authorization for Oxervate (cenegermin), with approval based on confirmed stage 2 or 3 neurotrophic keratitis diagnosis and documented failure of preservative-free artificial tears. Fastest path to approval: Have your ophthalmologist submit a complete prior authorization request including corneal sensitivity testing results, fluorescein staining documentation, and evidence of 14+ days of failed supportive care. Start today: Contact your specific Blue Cross Blue Shield plan's provider services to obtain their current Oxervate prior authorization form and submission requirements.

Table of Contents

  1. Blue Cross Blue Shield Washington Policy Overview
  2. Medical Necessity Requirements
  3. Step Therapy and Exception Pathways
  4. Quantity Limits and Renewal Rules
  5. Required Diagnostic Documentation
  6. Site of Care and Specialty Pharmacy Requirements
  7. Evidence to Support Medical Necessity
  8. Sample Medical Necessity Narrative
  9. Common Denial Reasons and Solutions
  10. Appeals Process in Washington
  11. Cost Assistance Programs
  12. FAQ

Blue Cross Blue Shield Washington Policy Overview

Washington state has multiple Blue Cross Blue Shield plans, including Premera Blue Cross and Regence BlueShield, each operating as independent entities under the Blue Cross Blue Shield Association. While specific policies vary by plan, all Washington Blues follow similar frameworks for specialty drug coverage requiring prior authorization.

Plan Types and Coverage:

  • Commercial plans (employer-sponsored and individual): Standard PA requirements apply
  • Medicare Advantage: Follow CMS guidelines with plan-specific formulary restrictions
  • Medicaid managed care: Apple Health plans may have additional state-mandated coverage protections
Note: Each Blue plan maintains its own formulary and prior authorization criteria. Always verify requirements with your specific plan using the member services number on your insurance card.

Medical Necessity Requirements

Oxervate coverage typically requires meeting these core medical necessity criteria across Blue Cross Blue Shield plans:

FDA-Approved Indication

  • Primary indication: Treatment of neurotrophic keratitis (stage 2 or 3)
  • Patient age: 2 years or older
  • Prescriber requirement: Ophthalmologist or in consultation with ophthalmology

Diagnostic Confirmation

  • Confirmed diagnosis of stage 2 (persistent epithelial defect) or stage 3 (corneal ulcer) neurotrophic keratitis
  • Documented corneal sensitivity testing showing decreased or absent sensation
  • Fluorescein staining demonstrating epithelial defects

Step Therapy and Exception Pathways

Most Blue Cross Blue Shield plans require documented trial and failure of conservative treatments before approving Oxervate.

Required Prior Therapies

  1. Preservative-free artificial tears: Minimum 14 days with documented progression
  2. Supportive care measures: May include bandage contact lenses, autologous serum tears, or protective eyewear

Medical Exception Pathways

Patients may bypass step therapy requirements if they have:

  • Contraindications to standard therapies
  • Previous intolerance to required treatments (documented in medical record)
  • Urgent clinical circumstances requiring immediate Oxervate therapy
Tip: Document specific reasons why each prior therapy failed, including dates of treatment and clinical response.

Quantity Limits and Renewal Rules

Standard Dosing Parameters

  • Dosage: 1 drop to affected eye(s) 6 times daily
  • Treatment duration: 8 weeks
  • Quantity limit: Typically 8 kits per affected eye for entire lifetime

Re-treatment Considerations

Some plans may approve additional courses for:

  • Documented recurrence of neurotrophic keratitis
  • Incomplete healing requiring extended therapy
  • New episodes in previously unaffected eyes

Required Diagnostic Documentation

Essential Clinical Evidence

Requirement Documentation Needed Source
Corneal sensitivity Cotton-tip test or Cochet-Bonnet aesthesiometer results Ophthalmology exam notes
Epithelial integrity Fluorescein staining photographs/descriptions Slit-lamp examination
Disease staging Clear documentation of stage 2 or 3 NK Clinical assessment
Prior treatment failure Dates, duration, and outcomes of conservative therapy Medical records

Diagnostic Testing Timeline

  • Corneal sensitivity testing: Within 30 days of PA request
  • Fluorescein staining: Current documentation showing active defects
  • Clinical photographs: Helpful but not always required

Site of Care and Specialty Pharmacy Requirements

Distribution Requirements

Oxervate is typically distributed through specialty pharmacies rather than retail locations. Common specialty pharmacy partners include:

  • Accredo Health Group
  • CVS Specialty (for Aetna-affiliated Blues)
  • Express Scripts Specialty (plan-dependent)

Administration Setting

  • Self-administration: Patients receive home delivery with administration supplies
  • Clinic administration: May be required for certain patient populations
  • Storage requirements: Refrigerated storage between 36-46°F
Note: Verify your specific Blue plan's preferred specialty pharmacy network to avoid coverage issues.

Evidence to Support Medical Necessity

Clinical Guidelines and Literature

Strong medical necessity letters reference:

  • FDA labeling for Oxervate's approved indication
  • American Academy of Ophthalmology guidelines on neurotrophic keratitis management
  • Peer-reviewed studies demonstrating Oxervate efficacy (70-74.5% healing rates in clinical trials)

Key Clinical Data Points

  • Corneal healing rates with Oxervate vs. standard care
  • Safety profile in long-term studies
  • Economic impact of preventing corneal perforation and surgical intervention

Sample Medical Necessity Narrative

Clinician Corner: Medical Necessity Template

"[Patient] is a [age]-year-old with stage [2/3] neurotrophic keratitis in the [right/left] eye, confirmed by [specific diagnostic method]. Corneal sensitivity testing demonstrates [absent/decreased] sensation, and fluorescein staining reveals [specific findings]. The patient has failed conservative management including [list specific treatments and duration]. Given the progressive nature of the condition and risk of corneal perforation, Oxervate (cenegermin) is medically necessary to promote corneal nerve regeneration and epithelial healing. The requested 8-week course aligns with FDA-approved dosing and has demonstrated superior efficacy compared to standard supportive care in clinical trials."

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Insufficient diagnostic documentation Submit corneal sensitivity testing results and fluorescein staining images
Inadequate prior therapy trial Provide detailed records of failed conservative treatments with specific dates
Off-label use Confirm diagnosis meets FDA-approved indication for stage 2/3 neurotrophic keratitis
Missing specialist evaluation Ensure ophthalmologist consultation is documented
Quantity exceeded Justify dosing based on number of affected eyes and treatment duration

Appeals Process in Washington

Washington state provides robust appeal protections through multiple levels of review.

Internal Appeals

  • Timeline: 180 days from denial to file
  • Decision timeframe: 30 days for standard, 72 hours for urgent
  • Required documentation: Original PA request plus additional supporting evidence

External Review (IRO)

After exhausting internal appeals, Washington patients can request Independent Review Organization (IRO) review:

  • Cost: Free to patients
  • Timeline: File within 21 days of final internal denial
  • Reviewer: Board-certified ophthalmologist independent of the insurance company
  • Decision: Binding on the insurer
Contact: Washington Office of Insurance Commissioner at 1-800-562-6900 for IRO assistance

Expedited Appeals

Available when delay could seriously jeopardize patient health:

  • Standard: 72-hour decision timeline
  • Emergency: Same-day review possible

Cost Assistance Programs

Manufacturer Support

  • Dompé CONNECT to Care: Patient assistance program offering financial support
  • Contact: 1-888-454-8860
  • Services: Insurance verification, prior authorization support, copay assistance

Foundation Grants

  • Patient Advocate Foundation
  • NeedyMeds
  • RxHope (verify current programs)

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements for specialty medications like Oxervate. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific criteria, improving approval rates and reducing administrative burden for busy ophthalmology practices.

FAQ

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard prior authorization decisions are typically made within 14 business days, with urgent requests processed within 72 hours.

What if Oxervate is non-formulary on my Blue plan? Non-formulary medications can still be covered through the formulary exception process, requiring enhanced documentation of medical necessity and prior therapy failures.

Can I request an expedited appeal if my PA is denied? Yes, if delay in treatment could seriously jeopardize your health, you can request expedited internal and external review with much faster decision timelines.

Does step therapy apply if I failed treatments outside Washington? Prior treatment records from other states are generally accepted, but ensure all documentation is transferred to your current ophthalmologist's records.

What happens if the external IRO upholds the denial? While IRO decisions are typically final, you can contact the Washington Office of Insurance Commissioner for guidance on potential next steps or file a complaint if you believe the review was improper.

How do I find my Blue Cross Blue Shield plan's specific Oxervate policy? Contact your plan's provider services line or check their online provider portal for current prior authorization criteria and required forms.

When to Escalate

Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 if:

  • Your plan fails to meet appeal deadlines
  • You need assistance navigating the external review process
  • You believe your plan is not following Washington insurance laws
  • You want to file a complaint about improper denial practices

For complex cases involving multiple denials or unusual circumstances, specialized services like Counterforce Health can provide targeted appeal strategies that address your specific Blue Cross Blue Shield plan's requirements and increase the likelihood of approval.

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage policies vary by specific Blue Cross Blue Shield plan and individual circumstances. Always consult with your healthcare provider regarding medical decisions and contact your insurance plan directly for current policy information. For personalized assistance with Washington insurance appeals, contact the Office of Insurance Commissioner at 1-800-562-6900.

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