By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by Cigna in Virginia: Prior Authorization Guide and Appeals Process

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

Eligibility: Cigna covers Oxervate for stage 2 or 3 neurotrophic keratitis with prior authorization. You must be prescribed by an ophthalmologist or optometrist and have failed preservative-free artificial tears for at least 14 days.

Fastest path: Submit PA request through CoverMyMeds or Express Scripts portal with complete staging documentation and failed treatment history. Standard approval takes 5 business days.

Start today: Gather your corneal sensitivity test results, fluorescein staining photos, and documentation of all prior treatments. Contact your eye doctor to begin the PA submission process.

Table of Contents

What This Guide Covers

This guide helps patients with neurotrophic keratitis and their eye care providers navigate Cigna's prior authorization process for Oxervate (cenegermin) in Virginia. Whether you're facing an initial request, dealing with a denial, or preparing for renewal, this step-by-step guide provides the forms, timelines, and appeal strategies specific to Virginia residents.

Oxervate is a breakthrough treatment for stage 2 and 3 neurotrophic keratitis—a rare condition where damaged corneal nerves prevent proper healing. At roughly six figures for an 8-week course, getting insurance approval requires careful documentation and persistence. The good news: Virginia has strong patient protections and an independent external review process that can overturn wrongful denials.

Before You Start: Verify Your Coverage

Check Your Plan Type

First, confirm whether you have a Cigna commercial plan, Medicare Advantage, or Medicaid managed care plan. The prior authorization process varies slightly:

  • Commercial plans: Standard PA through Express Scripts/Accredo
  • Medicare Advantage: May have additional Part D requirements
  • Medicaid: Different formulary and appeal timelines

Confirm Formulary Status

Oxervate's coverage varies by plan. Log into your Cigna member portal or call member services to check:

  • Tier placement (typically specialty tier with high copay)
  • Prior authorization requirement (required for all plans)
  • Quantity limits (8 weeks initial, 16 weeks lifetime maximum per eye)
  • Step therapy requirements (must fail artificial tears first)
Note: If Oxervate is non-formulary on your plan, you'll need to request a formulary exception along with the PA.

Gather What You Need

Clinical Documentation Required

Your ophthalmologist needs these specific documents for a successful PA:

Diagnosis Documentation:

  • Stage 2 or 3 neurotrophic keratitis confirmation with ICD-10 code H16.239
  • Corneal sensitivity test results (cotton wisp or Cochet-Bonnet aesthesiometer)
  • Slit-lamp examination findings with measurements
  • Fluorescein staining photos showing epithelial defects or stromal ulceration

Failed Treatment History:

  • Documentation of preservative-free artificial tears trial for ≥14 days
  • Specific products used, dates of treatment, and clinical outcomes
  • Any other failed therapies (ointments, bandage contact lenses, etc.)
  • Reasons for discontinuation or inadequate response

Supporting Records:

  • Complete ophthalmology consultation notes
  • Relevant imaging or diagnostic test results
  • Patient age confirmation (must be ≥2 years old)

Insurance Information

  • Current Cigna member ID card
  • Policy details and formulary information
  • Any previous denial letters or EOBs
  • Prescriber NPI and practice information

Submit the Prior Authorization Request

Step-by-Step Submission Process

  1. Download Forms: Your provider can access Cigna's PA forms (verify current link) or submit electronically.
  2. Submit Through Preferred Channels:
    • Electronic: CoverMyMeds portal (fastest)
    • EHR Integration: SureScripts within electronic health records
    • Express Scripts: For specialty pharmacy routing
  3. Include Complete Documentation:
    • Completed PA form with all required fields
    • Clinical notes supporting stage 2/3 diagnosis
    • Failed treatment documentation
    • Prescriber attestation letter
  4. Confirm Receipt: Request confirmation number and expected timeline
Tip: Mark urgent requests as "expedited" if there's risk of corneal perforation or vision loss. This can reduce approval time to 72 hours.

Medical Necessity Letter Checklist

Your eye doctor's letter should include:

  • Problem Statement: "Patient has confirmed stage [2/3] neurotrophic keratitis with [specific findings]"
  • Prior Treatments: "Failed preservative-free artificial tears for 14+ days, with [specific outcomes]"
  • Clinical Rationale: "Oxervate is FDA-approved and medically necessary to prevent [corneal perforation/vision loss]"
  • Monitoring Plan: "Will monitor corneal healing with weekly examinations"
  • Guideline Support: Reference FDA labeling and ophthalmology guidelines

Follow-Up and Timelines

Standard Processing Times

  • Initial Review: 5 business days for standard requests
  • Expedited Review: 72 hours for urgent medical situations
  • Additional Information: 14 days if Cigna requests more documentation

Follow-Up Best Practices

Week 1: Call Cigna member services if no response within 5 business days Sample Script: "I'm calling to check the status of prior authorization request #[number] for Oxervate submitted on [date]. Can you provide an update and expected timeline?"

Document Everything: Keep records of all phone calls, reference numbers, and representative names.

If You're Asked for More Information

Cigna may request additional documentation to support medical necessity:

Common Information Requests

Request Type How to Respond Timeline
Staging confirmation Submit detailed slit-lamp findings with photos 5-7 days
Treatment history Provide complete trial documentation with dates 3-5 days
Specialist consultation Include ophthalmology consultation notes 5-7 days
Clinical guidelines Attach FDA labeling and relevant studies 2-3 days

Peer-to-Peer Review

If Cigna requests a peer-to-peer discussion, your ophthalmologist should emphasize:

  • Objective findings: Specific corneal sensitivity measurements and staging
  • Failed alternatives: Detailed timeline of inadequate conservative treatments
  • Clinical urgency: Risk of progression without treatment
  • Evidence base: FDA approval and established clinical use

If Your Request Is Denied

Understanding Denial Codes

Common denial reasons and how to address them:

  • "Experimental/Investigational": Reference FDA approval and established clinical use
  • "Step therapy not met": Provide complete artificial tears trial documentation
  • "Not medically necessary": Submit additional clinical evidence and specialist letter
  • "Non-formulary": Request formulary exception with medical necessity justification

Internal Appeals Process

First-Level Appeal:

  • Timeline: 180 days from denial date to file
  • Response: 30 days for standard, 72 hours for expedited
  • Submit: Updated clinical documentation addressing denial reason

Second-Level Appeal:

  • Timeline: 60 days from first-level denial
  • Process: Independent clinical review
  • Success Rate: Higher with complete documentation and specialist support
From Our Advocates: We've seen patients succeed by including updated corneal photos showing disease progression and a detailed timeline of all treatments tried. The key is addressing the specific denial reason with objective clinical evidence.

Virginia External Review Process

If Cigna upholds their denial after internal appeals, Virginia's external review process provides an independent second opinion.

Eligibility and Timeline

  • Who Qualifies: Virginia residents with medical necessity denials
  • When to File: Within 120 days of final internal denial
  • Cost: Free to patients
  • Decision Timeline: 45 days standard, 72 hours expedited

How to File External Review

  1. Download Form 216-A from the Virginia State Corporation Commission website
  2. Gather Documentation: Final denial letter, medical records, physician recommendations
  3. Submit Complete Package: Include all supporting clinical evidence
  4. Additional Information: You have 5 business days after acceptance to submit extra documentation

External Review Success Factors

The independent review organization considers:

  • Complete medical records and clinical findings
  • Physician treatment recommendations
  • Relevant clinical guidelines and evidence
  • Terms of your insurance coverage

Virginia's external review has helped many patients access necessary treatments when insurance companies initially denied coverage.

Renewal and Re-Authorization

When to Start Renewal Process

  • Initial Course: 8 weeks maximum per affected eye
  • Re-treatment: Additional 8 weeks possible for recurrent disease
  • Timing: Submit renewal request 2-3 weeks before current authorization expires

Required Documentation for Renewal

  • Updated clinical examination findings
  • Evidence of treatment response or disease recurrence
  • Continued medical necessity justification
  • Any new relevant clinical information

Counterforce Health helps patients and providers navigate complex prior authorization processes like these, turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial reasons and creates comprehensive rebuttals aligned with each payer's specific requirements.

Cost and Patient Support

Manufacturer Support Programs

Dompé Farmaceutici offers patient assistance through their Oxervate support program. Eligible patients may receive:

  • Copay assistance for commercially insured patients
  • Patient assistance programs for uninsured/underinsured
  • Clinical and reimbursement support services

Additional Resources

  • Virginia Free Clinic Association: May provide assistance for uninsured patients
  • Patient Access Network Foundation: Copay assistance for rare disease treatments
  • National Organization for Rare Disorders: Patient advocacy and support

FAQ

Q: How long does Cigna prior authorization take in Virginia? A: Standard requests take 5 business days. Expedited requests for urgent medical situations are processed within 72 hours.

Q: What if Oxervate is non-formulary on my Cigna plan? A: Request a formulary exception along with the prior authorization. Include medical necessity documentation showing why formulary alternatives are inappropriate.

Q: Can I request an expedited appeal if my initial request is denied? A: Yes, if your physician certifies that delayed treatment could seriously harm your vision or eye health, you can request expedited review at each appeal level.

Q: Does Virginia's external review apply to all Cigna plans? A: Virginia's external review applies to state-regulated plans. Self-funded employer plans may opt in, but federal employees and some large employers may use federal external review processes.

Q: What happens if I'm already receiving Oxervate and Cigna stops coverage? A: File an expedited appeal immediately. Virginia law requires continued coverage during the appeal process for ongoing treatments in many cases.

Q: How much does Oxervate cost without insurance? A: An 8-week course typically costs in the low six figures. Manufacturer assistance and patient support programs can significantly reduce out-of-pocket costs.

Quick Reference Checklist

Before Submitting PA:

  • Confirm stage 2 or 3 neurotrophic keratitis diagnosis
  • Document failed artificial tears trial (≥14 days)
  • Gather corneal sensitivity test results
  • Obtain slit-lamp examination findings
  • Collect all prior treatment records
  • Verify prescriber is ophthalmologist/optometrist

PA Submission:

  • Complete Cigna PA form
  • Include medical necessity letter
  • Attach clinical documentation
  • Submit via CoverMyMeds or Express Scripts
  • Request confirmation number

If Denied:

  • Review denial reason carefully
  • File internal appeal within 180 days
  • Consider peer-to-peer review
  • Gather additional supporting evidence
  • Contact Virginia Bureau of Insurance if needed

For External Review:

  • Complete internal appeals first
  • Download Form 216-A from Virginia SCC
  • Submit within 120 days of final denial
  • Include all medical records and documentation

For complex cases or persistent denials, Counterforce Health specializes in creating comprehensive appeals that address payer-specific requirements and increase approval success rates.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical advice. Always consult with your healthcare provider about treatment decisions and follow their clinical recommendations. Insurance coverage policies and procedures may change; verify current requirements with your specific plan. For personalized assistance with insurance appeals in Virginia, contact the Virginia State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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