By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by Cigna in Illinois: Complete Forms, Appeals & Approval Guide

Quick Answer: Getting Oxervate (Cenegermin) Covered by Cigna in Illinois

Oxervate requires prior authorization from Cigna for neurotrophic keratitis treatment. Your ophthalmologist must submit a PA request through CoverMyMeds or fax (855) 840-1678 with documentation of stage 2/3 diagnosis and failed conservative treatments. Cigna covers up to 8 weeks initially (maximum 16 weeks per eye lifetime) when prescribed by an eye specialist. If denied, you have 180 days to appeal internally, then 30 days for Illinois external review through the Department of Insurance. Start by verifying your specific Cigna formulary and gathering prior treatment records.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Requirements
  3. Submission Methods & Portals
  4. Specialty Pharmacy Setup
  5. Appeal Process for Denials
  6. Illinois State Resources
  7. Common Denial Reasons & Solutions
  8. Cost Assistance Options
  9. FAQ

1. Verify Your Plan & Find the Right Forms

Before starting your Oxervate prior authorization, confirm your specific Cigna plan details:

Check Your Coverage:

  • Log into myCigna.com to view your prescription drug formulary
  • Look for "Oxervate" or "cenegermin" in the specialty tier
  • Note any step therapy or quantity limit requirements

Required Forms: Cigna uses standardized prior authorization forms that your prescriber will complete. The specific form depends on your plan type (commercial vs. Medicare Advantage). Your ophthalmologist's office typically handles this submission through their electronic systems.

Tip: Call Cigna member services at the number on your insurance card to confirm current PA requirements for your specific plan.

2. Prior Authorization Requirements

Coverage Criteria for Oxervate

Cigna approves Oxervate when these conditions are met:

Medical Requirements:

  • Documented stage 2 (persistent epithelial defect) or stage 3 (corneal ulcer) neurotrophic keratitis
  • Evidence of decreased corneal sensitivity in at least one eye
  • Patient age 2 years or older
  • Prescription by ophthalmologist or optometrist

Treatment History: You must have tried and failed ALL of these conservative treatments:

  • Over-the-counter artificial tears, gels, or lubricant ointments
  • Therapeutic contact lenses
  • Autologous serum eye drops (unless contraindicated)

Treatment Limits:

  • Initial course: Up to 8 weeks per affected eye
  • Maximum lifetime: 16 weeks total per eye (8 weeks initial + 8 weeks for recurrence)

Documentation Checklist

Your ophthalmologist needs to provide:

  • Complete eye exam findings showing stage 2/3 neurotrophic keratitis
  • Corneal sensitivity test results
  • Records of all prior treatments attempted and their outcomes
  • Clinical rationale for why surgical options aren't appropriate
  • Treatment plan with dosing (1 drop 6 times daily for 8 weeks)

3. Submission Methods & Portals

Electronic Submission (Fastest)

CoverMyMeds: Your prescriber can submit through www.covermymeds.com/main/prior-authorization-forms/cigna/

SureScripts: Available through most electronic health record systems

Alternative Methods

Fax: (855) 840-1678 for standard requests

Phone for Urgent Cases: (800) 882-4462

Response Time: Cigna provides decisions within 5 business days for standard requests. Urgent requests (when delay could harm your health) receive faster review.

Required Supporting Documents

  • Complete ophthalmology consultation notes
  • Diagnostic test results (corneal sensitivity, slit-lamp exam)
  • Prior treatment failure documentation
  • Patient's complete medical history related to the eye condition

4. Specialty Pharmacy Setup

Oxervate is dispensed through Accredo Specialty Pharmacy, Cigna's preferred specialty provider.

Setup Process:

  1. Your prescriber submits the PA request
  2. Once approved, Accredo contacts you to set up delivery
  3. Complete enrollment at patient.accredo.com or via phone
  4. Schedule shipments (medication requires refrigeration)

Key Details:

  • Each vial treats one eye for one day
  • Bilateral treatment requires 2 vials daily
  • 8-week course = 56 vials per eye
  • Free overnight shipping with temperature control
Note: Oxervate can also be obtained through physician office stock or ambulatory infusion centers, depending on your prescriber's preference.

5. Appeal Process for Denials

Internal Appeals with Cigna

Level 1 Appeal:

  • Deadline: 180 calendar days from denial date
  • Method: Submit through myCigna portal or call member services
  • Timeline: Decision within 30 days (15 days for pre-service)
  • Required: Original denial letter, additional medical records, prescriber letter

Level 2 Appeal:

  • Deadline: 60 days from Level 1 decision
  • Process: Automatic external physician review
  • Timeline: 30-45 days for decision

Expedited Appeals

If waiting could seriously harm your health, request expedited review:

  • Timeline: 24-hour decision with physician certification of urgency
  • Process: Your prescriber calls Cigna to request expedited status

Illinois External Review

If Cigna denies your internal appeals, Illinois law provides independent review:

Key Details:

  • Deadline: 30 days from final Cigna denial (shorter than most states)
  • Cost: Free to consumers
  • Authority: Independent physician reviewer's decision is binding
  • Contact: Illinois Department of Insurance at [email protected]

6. Illinois State Resources

Department of Insurance Consumer Assistance

Office of Consumer Health Insurance (OCHI):

  • Phone: (877) 527-9431
  • Services: Appeal guidance, external review filing, insurance complaint assistance

Illinois Attorney General Health Care Helpline:

  • Phone: (877) 305-5145
  • Services: Informal intervention with insurers, consumer advocacy

Filing External Review

Required Form: Illinois DOI External Review Form Submission: Email [email protected] or mail to: Illinois Department of Insurance 122 S. Michigan Ave., 19th Floor Chicago, IL 60603

Timeline: Independent physician decision within 5 business days of receiving complete file

7. Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Insufficient diagnosis documentation Provide detailed ophthalmology exam Stage 2/3 NK confirmation, corneal sensitivity test
Lack of prior treatment trials Document all conservative measures tried Treatment timeline with outcomes/failures
Prescriber not qualified Ensure ophthalmologist/optometrist prescription Board certification verification
Exceeds treatment duration limits Verify lifetime usage per eye Prior Oxervate treatment history
Not medically necessary Strengthen clinical rationale FDA labeling citations, treatment guidelines

Medical Necessity Letter Template

Your ophthalmologist should include:

  • Patient's specific NK stage and severity
  • Complete history of failed treatments with dates and outcomes
  • Why surgical options aren't appropriate
  • Expected treatment goals and monitoring plan
  • Citations from FDA labeling and ophthalmology guidelines

8. Cost Assistance Options

Manufacturer Support:

  • Dompé Farmaceutici may offer patient assistance programs
  • Contact manufacturer directly for current offerings

Foundation Grants:

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • Disease-specific foundations for underlying conditions

Illinois Medicaid:

  • Expanded Medicaid covers many specialty medications
  • Contact Illinois Department of Human Services for eligibility
From our advocates: We've seen cases where patients initially denied for "insufficient documentation" were approved after their ophthalmologist submitted a detailed letter citing specific FDA labeling sections about neurotrophic keratitis treatment. The key was showing that conservative treatments had been systematically tried over months, not just mentioned briefly.

9. FAQ

How long does Cigna prior authorization take for Oxervate? Standard requests receive decisions within 5 business days. Urgent requests are processed within 24-48 hours when medical urgency is documented.

What if Oxervate isn't on my Cigna formulary? Request a formulary exception through your prescriber. Provide medical necessity documentation showing why preferred alternatives aren't appropriate.

Can I get expedited appeals in Illinois? Yes, if your prescriber certifies that waiting would seriously jeopardize your health. Cigna must respond to expedited appeals within 24 hours.

What happens if I've already tried Oxervate before? Cigna may approve retreatment if you've had fewer than 16 total weeks per affected eye and there's clinical justification for retreatment.

Does step therapy apply to Oxervate? Yes, you must try conservative treatments (artificial tears, contact lenses, serum drops) before Oxervate approval, unless contraindicated.

How do I know if my appeal was successful? Cigna sends written notification of all appeal decisions. Approvals include coverage effective dates and any limitations.

When Coverage Gets Complex

Navigating specialty drug approvals like Oxervate can be overwhelming, especially when dealing with rare conditions like neurotrophic keratitis. Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create evidence-backed rebuttals. Their platform helps patients and clinicians identify specific denial reasons and draft targeted appeals that address payer requirements while incorporating the right medical evidence and procedural details.

For Illinois residents facing Oxervate denials, having expert guidance on appeal strategy can make the difference between continued denials and successful coverage. The platform's understanding of payer-specific workflows and Illinois appeal timelines helps ensure that appeals meet both clinical and procedural requirements for approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and requirements may vary by plan and change over time.

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