How to Get Oxervate (Cenegermin) Covered by Cigna in North Carolina: Prior Authorization, Appeals, and Approval Guide
Answer Box: Quick Eligibility Check
To get Oxervate (cenegermin) covered by Cigna in North Carolina, you need: (1) Stage 2 or 3 neurotrophic keratitis diagnosed by an ophthalmologist, (2) documented failure of preservative-free artificial tears for 4-6 weeks, and (3) prior authorization through Accredo specialty pharmacy. First step today: Have your eye doctor submit a Cigna Oxervate PA form with corneal sensitivity test results and prior treatment timeline. If denied, North Carolina's Smart NC external review program overturns 40-50% of medical necessity denials and is binding on Cigna.
Table of Contents
- How to Use This Decision Tree
- Eligibility Triage: Do You Qualify?
- If "Likely Eligible": Document Checklist & Submission
- If "Possibly Eligible": Tests to Request
- If "Not Yet": Alternatives to Discuss
- If Denied: Appeal Path Chooser
- Coverage Requirements at a Glance
- Common Denial Reasons & How to Fix Them
- Frequently Asked Questions
- Resources & Next Steps
How to Use This Decision Tree
This guide walks you through Cigna's specific requirements for Oxervate (cenegermin) coverage in North Carolina. Start with the eligibility triage below to determine your pathway. Each section includes links to official forms and policies you'll need.
Note: Oxervate costs approximately $42,000-$50,000 for an 8-week course and requires specialty pharmacy dispensing through Accredo.
Eligibility Triage: Do You Qualify?
Answer these questions to determine your approval pathway:
✅ Likely Eligible if you have ALL of these:
- Stage 2 or 3 neurotrophic keratitis confirmed by ophthalmologist
- Decreased/absent corneal sensation documented by testing
- Failed preservative-free artificial tears for 4+ weeks
- Age 2 years or older
- No prior Oxervate treatment in the affected eye
⚠️ Possibly Eligible if you have MOST but not all:
- Neurotrophic keratitis diagnosis but staging unclear
- Some corneal sensation loss but not formally tested
- Tried artificial tears but timeline/response not documented
- Other eye conditions present (dry eye, exposure keratopathy)
❌ Not Yet Eligible if:
- No confirmed neurotrophic keratitis diagnosis
- Normal corneal sensation
- Haven't tried conservative treatments
- Already completed 8-week Oxervate course in same eye
If "Likely Eligible": Document Checklist & Submission
Required Documentation
Clinical Records Needed:
- Eye exam notes confirming stage 2/3 neurotrophic keratitis
- Corneal sensitivity test results (Cochet-Bonnet or cotton wisp)
- Fluorescein staining photos showing epithelial defect/ulcer
- Timeline of failed treatments with dates and outcomes
- ICD-10 diagnosis code (typically H16.09 for keratitis)
Prior Therapy Documentation:
- Preservative-free artificial tears (minimum 4-6 weeks)
- Antibiotic prophylaxis if used
- Bandage contact lens trial (if attempted)
- Other treatments: autologous serum, punctal plugs, ointments
Submission Process
- Get the right form: Cigna Oxervate PA form
- Prescriber requirement: Must be ophthalmologist or optometrist
- Submit via: CoverMyMeds portal, Express Scripts ePA, or fax to number on form
- Mark urgent if: Risk of corneal perforation or vision loss (72-hour review)
- Standard timeline: 5-15 business days for determination
Clinician Corner: Include this language in your medical necessity letter: "Patient has stage [2/3] neurotrophic keratitis per Mackie classification with markedly reduced corneal sensation documented by [test method]. Despite 6 weeks of preservative-free artificial tears and [other treatments], the epithelial defect persists at [size] mm, requiring advanced therapy to prevent progression to perforation."
If "Possibly Eligible": Tests to Request
Ask your ophthalmologist to:
Complete Missing Assessments
- Formal corneal sensitivity testing using Cochet-Bonnet aesthesiometer or standardized cotton wisp protocol
- Staging documentation with slit lamp exam and fluorescein staining
- Photography of corneal defect with measurements
- Review of prior treatments with specific dates, durations, and responses
Timeline to Re-apply
- Allow 2-4 weeks to gather complete documentation
- Ensure conservative therapy trial of at least 4-6 weeks before resubmitting
- Consider peer-to-peer review request if borderline case
If "Not Yet": Alternatives to Discuss
Conservative Treatments to Try First
- Preservative-free artificial tears 4-6 times daily for 6+ weeks
- Lubricating ointment at bedtime
- Bandage contact lens for persistent defects
- Autologous serum tears (if available)
- Punctal occlusion for severe dry eye component
Prepare for Exception Requests
- Document contraindications to standard therapy
- Note rapid progression or high perforation risk
- Consider formulary exception if Oxervate is non-formulary on your plan
If Denied: Appeal Path Chooser
North Carolina offers strong appeal rights through both Cigna's internal process and the state's Smart NC external review program.
Level 1 Internal Appeal (Cigna)
- Deadline: 180 days from denial
- Timeline: 30 days standard, 72 hours if urgent
- Required: Enhanced medical necessity letter addressing each denial reason
- Success rate: 70-78% for well-documented appeals
Level 2 Internal Appeal
- Deadline: 60 days from Level 1 denial
- Include: New clinical evidence, peer-to-peer review request
- Tip: Request phone consultation between your ophthalmologist and Cigna medical director
Smart NC External Review (North Carolina)
- When: After exhausting Cigna internal appeals
- Deadline: 120 days from final Cigna denial
- Eligibility: Fully-insured Cigna plans (not self-funded employer plans)
- Success rate: 40-50% overturn rate for medical necessity denials
- Timeline: 45 days standard, 72 hours urgent
- Cost: Free to patients
- Contact: Smart NC helpline 1-855-408-1212
From our advocates: We've seen several North Carolina patients successfully overturn Cigna denials for expensive eye medications through Smart NC external review. The key was submitting comprehensive ophthalmology records showing disease progression and failed conservative treatments. While outcomes aren't guaranteed, the independent medical reviewers often have different perspectives than internal insurance reviewers.
Coverage Requirements at a Glance
| Requirement | Details | Source |
|---|---|---|
| Prior Authorization | Required for all Oxervate prescriptions | Cigna PA Policy |
| Diagnosis | Stage 2 or 3 neurotrophic keratitis | FDA Label |
| Age Limit | ≥ 2 years old | FDA Label |
| Prescriber | Ophthalmologist or optometrist | Cigna PA Policy |
| Prior Therapy | Failed preservative-free tears ≥ 4 weeks | Cigna PA Policy |
| Dosing | 1 drop 6 times daily for 8 weeks | FDA Label |
| Pharmacy | Accredo specialty pharmacy only | Accredo |
| Quantity Limit | 56 vials (1 eye) or 112 vials (both eyes) | Cigna PA Policy |
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn |
|---|---|
| "Insufficient documentation of neurotrophic keratitis" | Submit detailed eye exam with staging, corneal sensitivity test results, and fluorescein photos |
| "Step therapy not met" | Provide timeline of preservative-free tears, antibiotics, bandage lenses with dates and outcomes |
| "Not medically necessary" | Include medical necessity letter citing FDA labeling and risk of corneal perforation |
| "Prescriber not qualified" | Ensure prescription from ophthalmologist; include credentials if requested |
| "Experimental/investigational" | Reference FDA approval and established guidelines for neurotrophic keratitis treatment |
Frequently Asked Questions
How long does Cigna prior authorization take in North Carolina? Standard review takes 5-15 business days. Mark urgent for 72-hour review if there's risk of corneal perforation or vision loss.
What if Oxervate is not on my Cigna formulary? Request a formulary exception with medical necessity documentation. Cigna has specific exception processes for non-formulary specialty drugs.
Can I get expedited appeals in North Carolina? Yes, both Cigna internal appeals and Smart NC external review offer expedited timelines (72 hours) for urgent medical situations.
Does Cigna cover re-treatment with Oxervate? Most Cigna policies limit coverage to one 8-week course per eye per lifetime. Re-treatment requires exceptional clinical justification.
What happens if Smart NC overturns Cigna's denial? The decision is binding on Cigna. They must provide coverage within 3 business days of the external review decision.
Who can help me navigate the appeals process? Smart NC advocates provide free assistance at 1-855-408-1212. Counterforce Health also helps patients and clinicians turn denials into successful appeals with evidence-backed documentation.
Are there patient assistance programs for Oxervate? Yes, Dompé offers the CONNECT to Care program which provides benefits investigation, prior authorization support, and copay assistance for eligible patients.
Resources & Next Steps
Essential Links
- Cigna Oxervate Prior Authorization Form
- North Carolina Smart NC External Review
- Oxervate Prescribing Information
- Accredo Specialty Pharmacy Referral
What to Do Today
- Confirm your Cigna plan type (fully-insured vs. self-funded) by calling member services
- Schedule ophthalmology consultation if you haven't seen a specialist
- Gather prior treatment records with dates and outcomes
- Download the PA form and review requirements with your doctor
When dealing with insurance coverage challenges, remember that persistence and proper documentation are key. Counterforce Health specializes in helping patients navigate complex prior authorization requirements and appeals processes, turning insurance denials into targeted, evidence-backed approvals for medications like Oxervate.
Disclaimer: This information is for educational purposes only and is not medical advice. Insurance coverage decisions depend on your specific plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For official North Carolina insurance assistance, contact Smart NC at 1-855-408-1212.
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