By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by Cigna in Ohio: Complete Approval Guide

Answer Box: Getting Oxervate Covered by Cigna in Ohio

Oxervate (cenegermin) requires prior authorization from Cigna for stage 2 or 3 neurotrophic keratitis. The fastest path to approval: (1) Have your ophthalmologist document failed conventional treatments and confirm your NK stage, (2) Submit the PA request through Cigna's provider portal with complete clinical records, and (3) If denied, file an internal appeal within 180 days. Ohio residents can request external review through the Ohio Department of Insurance after exhausting internal appeals—decisions come within 30 days and are binding on Cigna.

Table of Contents

Understanding Cigna's Oxervate Requirements

Cigna requires prior authorization for Oxervate (cenegermin) based on specific clinical criteria. According to Cigna's coverage policy, the medication is covered for:

Coverage at a Glance

Requirement What It Means Where to Find It
Diagnosis Stage 2 or 3 neurotrophic keratitis only Clinical notes with staging documentation
Prescriber Must be an ophthalmologist Board certification verification
Prior Therapy Failed conventional treatments required Treatment history with dates and outcomes
Duration Up to 8 weeks per eye, per episode Maximum 16 weeks total per eye
Specialty Pharmacy Must use Accredo Cigna specialty pharmacy network
Note: Cigna typically manages specialty drugs like Oxervate through Express Scripts and Accredo. You'll need to enroll with Accredo (877-826-7657) for dispensing and clinical support.

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis (Patient + Ophthalmologist)

Your ophthalmologist must document stage 2 or 3 neurotrophic keratitis using specific clinical findings:

  • Stage 2: Persistent epithelial defect with rolled edges
  • Stage 3: Corneal ulcer with stromal involvement or melting

Timeline: Same-day documentation during your eye exam Required: Slit-lamp findings, corneal sensitivity testing, fluorescein staining results

2. Document Prior Treatment Failures (Ophthalmologist)

Cigna requires proof that conventional therapies have failed, including:

  • Preservative-free artificial tears
  • Therapeutic contact lenses
  • Ointments or gels
  • Punctal plugs

Timeline: Compile 2-4 weeks of treatment history Required: Specific product names, dates tried, and documented outcomes

3. Submit Prior Authorization Request (Clinic Staff)

Submit through Cigna's provider portal or fax the completed PA form with:

  • Clinical notes with NK staging
  • Treatment failure documentation
  • Ophthalmologist attestation
  • Patient insurance information

Timeline: Cigna typically responds within 72 hours to 14 days Portal: Access through Cigna provider portal (confirm current link)

4. Enroll with Accredo (Patient)

Call 877-826-7657 to enroll with Cigna's specialty pharmacy partner. Required: Insurance ID, prescriber contact, home delivery address Timeline: 24-48 hours for enrollment, 3-5 days for first shipment

5. Monitor Authorization Status (Patient + Clinic)

Track your request through myCigna.com or by calling member services. Timeline: Follow up if no response within 14 days

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Insufficient staging documentation Submit detailed slit-lamp exam with specific stage 2/3 findings and corneal photos
Inadequate prior therapy documentation Provide treatment log with dates, products, durations, and failure reasons
Non-specialist prescriber Ensure prescription comes from board-certified ophthalmologist
Exceeds duration limits Justify retreatment with documentation of recurrence and prior response
Off-label use Confirm diagnosis matches FDA-approved indication (neurotrophic keratitis only)

Appeals Playbook for Cigna in Ohio

Internal Appeal Process

If Cigna denies your initial request, you have 180 days to file an internal appeal:

Level 1 Internal Appeal:

  • Submit written appeal with new clinical evidence
  • Request peer-to-peer review with ophthalmology consultant
  • Timeline: 30 days for standard review, 72 hours for urgent
  • Submit to: Cigna appeals department (address on denial letter)

Level 2 Internal Appeal:

  • Available if Level 1 is denied
  • Timeline: 30 days for decision
  • Must exhaust before external review

Ohio External Review Process

After completing Cigna's internal appeals, Ohio residents can request binding external review through the Ohio Department of Insurance.

Key Facts:

  • Deadline: 180 days from Cigna's final denial
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Cost: Free to patients
  • Outcome: Binding on Cigna if overturned

How to File:

  1. Complete external review form (available on denial letter or ODI website)
  2. Submit to Cigna (they forward to Ohio DOI)
  3. Include all medical records and physician statements
  4. Specify if urgent review is needed
Ohio Advantage: The Ohio Department of Insurance can independently determine eligibility for external review, even if Cigna initially claims your case doesn't qualify.

Clinician Corner: Medical Necessity Documentation

Essential Elements for Approval

Diagnosis Documentation:

  • Specific staging (stage 2 or 3 neurotrophic keratitis)
  • ICD-10 codes (H16.223 for stage 3, right eye)
  • Corneal sensitivity measurements
  • Slit-lamp examination findings
  • Serial photography showing persistent defects

Prior Treatment Documentation:

  • Complete list of failed therapies with:
    • Product names and NDC numbers
    • Treatment duration and frequency
    • Dates of initiation and discontinuation
    • Specific reasons for failure or intolerance

Clinical Rationale:

  • Risk of progressive vision loss without treatment
  • Lack of effective alternatives
  • Patient-specific factors supporting Oxervate use
  • Treatment goals and monitoring plan

Key Clinical References

Scripts & Templates

Patient Phone Script for Cigna

"Hi, I'm calling to check on the prior authorization status for my Oxervate prescription. My member ID is [ID number], and my ophthalmologist submitted the request on [date]. Can you tell me the current status and if any additional information is needed?"

Peer-to-Peer Request Script (Clinic Staff)

"I'm requesting a peer-to-peer review for a denied Oxervate prior authorization. The patient has documented stage [2/3] neurotrophic keratitis with failed conventional therapy. Can we schedule a call with your ophthalmology consultant to discuss the medical necessity?"

Appeal Letter Template

Include these key elements:

  • Patient demographics and policy information
  • Specific denial reason being contested
  • Updated clinical evidence not in original submission
  • References to Cigna's own coverage criteria
  • Ophthalmologist's professional opinion on medical necessity

Costs & Financial Assistance

Oxervate typically costs in the low six figures for an 8-week course. Financial assistance options include:

Manufacturer Support:

  • Dompé patient assistance programs
  • Copay assistance for eligible patients
  • Contact manufacturer directly for current programs

Specialty Pharmacy Support:

  • Accredo offers financial counseling services
  • Help navigating insurance benefits and copay assistance
  • Call 877-826-7657 for assistance

Foundation Grants:

  • Patient advocacy organizations for rare diseases
  • State pharmaceutical assistance programs in Ohio
  • Hospital charity care programs

FAQ: Your Top Questions Answered

How long does Cigna prior authorization take in Ohio? Standard PA requests typically receive responses within 72 hours to 14 days. Urgent requests are processed within 72 hours if clinical urgency is documented.

What if Oxervate is non-formulary on my Cigna plan? You can request a formulary exception with medical justification. Your ophthalmologist must demonstrate medical necessity and lack of effective formulary alternatives.

Can I request expedited review for my appeal? Yes, if your ophthalmologist certifies that delays could seriously jeopardize your health or vision. Ohio external reviews can be expedited to 72 hours.

Does step therapy apply to Oxervate? Yes, Cigna requires documentation of failed conventional treatments before approving Oxervate. This includes artificial tears, therapeutic contact lenses, and other supportive measures.

What happens if my appeal is denied? After exhausting Cigna's internal appeals, you can request external review through the Ohio Department of Insurance. Their decision is binding on Cigna.

How do I get help with the appeals process in Ohio? Contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526 for assistance with appeals and external reviews.

From our advocates: "We've seen Oxervate appeals succeed when patients and doctors work together to document the progression from conservative treatments to the need for this specialized therapy. The key is showing Cigna exactly how their own criteria are met—stage confirmation, treatment failures, and ophthalmology expertise. While every case is different, thorough documentation paired with Ohio's patient-friendly external review process gives families a strong path forward."

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific denial basis, and creates targeted, evidence-backed rebuttals aligned to each payer's requirements. For complex cases like Oxervate approvals, we help gather the right clinical evidence and craft compelling medical necessity arguments that address payer-specific workflows and procedural requirements.

Sources & Further Reading

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. For questions about Ohio insurance regulations, contact the Ohio Department of Insurance at 1-800-686-1526.

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