By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by Cigna in California: Forms, Appeals, and Approval Guide

Answer Box: Getting Oxervate (Cenegermin) Covered by Cigna in California

Cigna requires prior authorization for Oxervate (cenegermin) to treat stage 2 or 3 neurotrophic keratitis in patients ≥2 years old. You'll need documentation of failed preservative-free artificial tears (≥4 weeks) and reduced corneal sensation testing. Download the Cigna Oxervate PA form, submit via CoverMyMeds or fax to 855-840-1678, and expect 5-15 business days for review. If denied, file a California Independent Medical Review (IMR) through the DMHC after exhausting Cigna's internal appeals.

First step today: Verify your plan type by calling the number on your Cigna ID card and confirm PA requirements.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Specialty Pharmacy Setup Through Accredo
  5. Appeals Process: Internal and California IMR
  6. Support Lines and Contacts
  7. Common Denial Reasons and Solutions
  8. California-Specific Resources

Verify Your Plan and Find the Right Forms

Before starting the approval process, confirm whether your Cigna plan is fully-insured (follows Cigna's standard policies) or self-funded (may have custom rules). Call the customer service number on your ID card and ask:

  • "Is my plan fully-insured or self-funded?"
  • "Does Oxervate require prior authorization?"
  • "Which specialty pharmacy do I need to use?"

Most Cigna members follow the national Oxervate policy, which requires PA for all members regardless of state.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all ages ≥2 years Cigna Policy
Diagnosis Stage 2 or 3 neurotrophic keratitis (Mackie classification) FDA Label
Prior Therapy Failed preservative-free artificial tears ≥4 weeks Cigna Policy
Initial Approval Up to 8 weeks per eye (56 vials/eye) Cigna Policy
Specialty Pharmacy Accredo required Cigna Member Guide
Appeals Deadline 180 days from denial notice Cigna Appeals Process

Prior Authorization Forms and Requirements

Required Documentation

Download the Cigna Oxervate Clinical Review Document (CRD) PA form and gather these supporting documents:

Medical Records Required:

  • Ophthalmology consultation notes confirming stage 2 or 3 neurotrophic keratitis
  • Corneal sensitivity test results (Cochet-Bonnet esthesiometer or cotton wisp test)
  • Fluorescein staining photographs showing persistent epithelial defects
  • Documentation of prior therapy timeline with specific dates and outcomes

Key Clinical Information:

  • ICD-10 diagnosis code (e.g., H16.09 for neurotrophic keratoconjunctivitis)
  • Patient age (must be ≥2 years)
  • Affected eye(s) and severity staging
  • Prior treatment failures with preservative-free artificial tears for ≥4 weeks
Clinician Corner: Your medical necessity letter should state: "Patient has stage [2/3] neurotrophic keratitis per Mackie classification with reduced corneal sensation confirmed by [specific test]. Conservative management with preservative-free artificial tears for [X weeks] has failed to achieve epithelial healing, as documented by persistent defects on fluorescein staining dated [date]."

Step-by-Step: Fastest Path to Approval

  1. Prescriber completes PA form - Download current form, complete all sections including clinical rationale
  2. Gather supporting documents - Collect ophthalmology notes, test results, and prior therapy documentation
  3. Submit via preferred portal - Use CoverMyMeds, Express Scripts ePA, or SureScripts for fastest processing
  4. Mark urgent if applicable - For patients at risk of corneal perforation or vision loss (72-hour review)
  5. Track submission - Call 800-882-4462 to confirm receipt and check status
  6. Await determination - Standard review: 5-15 business days; urgent: 72 hours
  7. If approved, enroll in Accredo - Specialty pharmacy will contact patient for enrollment

Submission Portals and Methods

Electronic Submission (Fastest)

  • CoverMyMeds portal - Preferred method for most prescribers
  • Express Scripts ePA - Direct electronic prior authorization
  • SureScripts - Integrated with many EMR systems

Fax Submission

  • PA requests: 855-840-1678
  • Appeals: Use fax number provided in denial letter
  • Include cover sheet with member ID, prescriber NPI, and "URGENT" if applicable

Phone Support

  • Expedited reviews: Call 800-882-4462 to request urgent processing
  • Status checks: Same number for submission tracking

Specialty Pharmacy Setup Through Accredo

Once Oxervate is approved, Cigna requires dispensing through Accredo Specialty Pharmacy. Your prescriber must complete the enrollment process:

Prescriber Requirements

  1. Complete Accredo Prescription & Enrollment Form
  2. Fax to 888-302-1028 with all required signatures (no stamps accepted)
  3. Include clinical information: ICD-10 code, patient weight/height, concurrent medications

Patient Portal Access

  • Cigna members: Access through your Cigna account → Prescriptions → "My Medications"
  • Direct registration: Visit Accredo.com with your Rx number
  • Support: Call 844-516-3319 for enrollment assistance

At Counterforce Health, we help patients and clinicians navigate complex specialty drug approvals like Oxervate. Our platform analyzes denial patterns and creates targeted appeals using payer-specific evidence requirements, significantly improving approval rates for rare disease treatments.

Appeals Process: Internal and California IMR

Cigna Internal Appeals

If your initial PA request is denied, you have 180 days to file an internal appeal:

  1. Level 1 Appeal - Submit new clinical evidence, request peer-to-peer review
  2. Level 2 Appeal - Independent medical review within Cigna
  3. Expedited Appeal - Available for urgent medical situations

California Independent Medical Review (IMR)

California residents have additional appeal rights through the Department of Managed Health Care:

Eligibility: Medical necessity denials for covered prescription drugs Timeline: File within 6 months of final Cigna denial Process:

  1. Complete DMHC IMR application
  2. Submit supporting medical records and physician statement
  3. DMHC assigns independent medical expert review
  4. Decision within 30 days (expedited: 72 hours for urgent cases)

Success Rate: California IMRs overturn approximately 73% of health plan denials

Note: IMR is free for patients, and the decision is binding on Cigna

Support Lines and Contacts

Member Services

  • Cigna Customer Service: Number on your ID card
  • Prior Authorization Status: 800-882-4462
  • Accredo Specialty Pharmacy: 844-516-3319

California Consumer Assistance

  • DMHC Help Center: 888-466-2219 (free IMR assistance)
  • Health Consumer Alliance: 888-804-3536 (nonprofit support)

What to Ask When You Call:

  • "What is the status of PA request #[number]?"
  • "What additional documentation is needed?"
  • "Can you schedule a peer-to-peer review with my prescriber?"
  • "How do I request an expedited review?"

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Insufficient prior therapy Document ≥4 weeks of preservative-free artificial tears with dates and outcomes Pharmacy records, clinical notes with specific trial periods
Lack of stage confirmation Provide clear staging per Mackie classification with corneal sensation testing Ophthalmology exam notes, esthesiometry results, fluorescein photos
Missing medical necessity Submit detailed letter explaining why Oxervate is clinically appropriate Medical necessity letter citing FDA labeling and clinical guidelines
Non-formulary status Request formulary exception with clinical justification Exception request form with comparative effectiveness data

California-Specific Resources

State Insurance Regulators

  • Department of Managed Health Care (DMHC): Oversees most HMOs and managed care plans
  • California Department of Insurance (CDI): Regulates some PPO and indemnity plans
  • Both offer free consumer assistance and independent review processes

Consumer Rights

California law provides enhanced appeal rights including:

  • No-cost Independent Medical Review
  • Expedited review for urgent cases (72 hours)
  • Binding decisions that insurers must follow
  • Multi-language support for non-English speakers

Getting Help

The DMHC Help Center provides free assistance with:

  • Filing complaints and IMR applications
  • Understanding your appeal rights
  • Navigating complex coverage disputes
  • Connecting with legal aid organizations

Frequently Asked Questions

How long does Cigna PA take in California? Standard review is 5-15 business days. Urgent requests (risk of corneal perforation) are reviewed within 72 hours.

What if Oxervate is non-formulary on my plan? Request a formulary exception by documenting medical necessity and failure of formulary alternatives. Include clinical evidence supporting Oxervate's unique mechanism of action.

Can I get an expedited appeal? Yes, if there's imminent risk of vision loss or corneal perforation. Mark requests "URGENT" and call 800-882-4462 to expedite.

Does step therapy apply to Oxervate? Most Cigna policies require documented failure of preservative-free artificial tears for ≥4 weeks, but formal step therapy protocols vary by plan.

What happens if my internal appeal is denied? California residents can file an IMR with the DMHC, which has a 73% overturn rate for medical necessity denials.

When to Use Counterforce Health

Complex specialty drug appeals like Oxervate often require detailed medical evidence and payer-specific strategies. Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial patterns, identifying the specific evidence requirements for each payer, and crafting targeted rebuttals that address the plan's own coverage criteria.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may vary by plan and change over time. Always verify current requirements with your insurance plan and consult with your healthcare provider for medical decisions.

Sources & Further Reading

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