By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by Humana in Illinois: Appeals Guide and Medical Necessity Templates

Answer Box: Getting Oxervate (Cenegermin) Covered by Humana in Illinois

Humana requires prior authorization for Oxervate (cenegermin) as a specialty-tier Part D drug for stage 2-3 neurotrophic keratitis. Your fastest path to approval: (1) Verify formulary status via Humana's PA Search Tool, (2) Submit PA request with confirmed NK diagnosis, corneal sensation testing, and documented failure of preservative-free artificial tears, (3) Include medical necessity letter citing FDA indication and peer-reviewed evidence. Standard timeline: 72 hours for Part D decisions. If denied, you have 65 days to appeal and access to Illinois's independent external review process with 30-day deadline for final decisions.

Table of Contents

  1. Understanding Your Denial Letter
  2. Coverage Requirements at a Glance
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Medical Necessity Letter Checklist
  6. Appeals Process for Humana in Illinois
  7. Scripts & Templates
  8. Illinois External Review Process
  9. Financial Assistance Options
  10. FAQ

Understanding Your Denial Letter

When Humana denies Oxervate (cenegermin), your denial notice will include specific reason codes. Here's how to decode them:

Common denial codes:

  • Non-formulary: Drug not on Humana's approved list
  • Prior authorization required: Clinical review needed before approval
  • Step therapy: Must try cheaper alternatives first
  • Quantity limits exceeded: Requesting more than plan allows
  • Medical necessity: Insufficient clinical documentation
Critical: Note the appeal deadline on your denial letter. For Humana Medicare plans, you have 65 days from the denial date to file an appeal.

Check whether this is a Part D pharmacy benefit (most common for Oxervate) or Part B medical benefit denial, as appeal processes differ slightly.

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all Oxervate prescriptions Humana PA Lists
Formulary Status Typically non-formulary or Tier 4 specialty PA Search Tool
Diagnosis Stage 2 or 3 neurotrophic keratitis with ICD-10 documentation FDA Label
Prior Therapy Failed preservative-free artificial tears for ≥2 weeks Standard payer requirement
Prescriber Ophthalmologist or corneal specialist Typical specialty requirement
Timeline Standard: 72 hours; Expedited: 24 hours if urgent CMS Part D Guidelines

Step-by-Step: Fastest Path to Approval

1. Verify Coverage Status

Who: Patient or clinic staff
Action: Call Humana member services (number on insurance card) or use the PA Search Tool
Timeline: Same day

2. Gather Required Documentation

Who: Ophthalmologist and patient
Documents needed:

  • Confirmed stage 2/3 neurotrophic keratitis diagnosis
  • Corneal sensation testing results (Cochet-Bonnet or cotton wisp)
  • Documentation of failed artificial tears (type, duration, outcome)
  • Slit-lamp photos showing epithelial defect or stromal ulcer
  • Complete eye exam notes

3. Submit Prior Authorization Request

Who: Prescribing physician
Method: Humana Provider Portal or fax
Include: Medical necessity letter (see checklist below)
Timeline: Submit within 1-2 business days of gathering docs

4. Request Formulary Exception (if needed)

Who: Physician
When: If Oxervate is non-formulary
Action: Submit exception request simultaneously with PA

5. Follow Up on Decision

Timeline: Check status after 48-72 hours
Next steps: If approved, coordinate with specialty pharmacy; if denied, proceed to appeals process

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Insufficient diagnosis documentation Submit detailed ophthalmology notes with stage 2/3 NK confirmation, corneal sensation testing, and fluorescein staining photos
Lack of prior therapy documentation Provide records showing ≥2 weeks of preservative-free artificial tears at optimal frequency with inadequate response
Non-formulary status File formulary exception with medical necessity justification citing no suitable alternatives
Experimental/investigational Cite FDA approval for NK (December 2018) and include FDA label excerpt
Quantity limits Justify 8-week course per FDA dosing (1 drop 6x daily) with treatment timeline

Medical Necessity Letter Checklist

Essential Elements for Your Ophthalmologist to Include:

Patient Information:

  • Full diagnosis: "Neurotrophic keratitis, stage [2/3], [right/left/bilateral] eye(s)"
  • ICD-10 code: H16.239 (or eye-specific variant)
  • Duration of condition and symptoms

Clinical Documentation:

  • Corneal sensation testing method and results
  • Size and location of epithelial defect or stromal ulcer
  • Slit-lamp examination findings
  • Risk factors (prior HSV keratitis, diabetes, trigeminal nerve damage, etc.)

Prior Treatments and Outcomes:

  • Specific artificial tears used (brand, frequency, duration)
  • Other supportive measures tried (bandage contact lenses, tarsorrhaphy, serum tears)
  • Why each treatment failed or was inappropriate

Medical Necessity Justification:

  • Risk of progression to perforation without treatment
  • Lack of effective formulary alternatives
  • Citation of FDA indication and clinical trial data
  • Expected treatment outcome and monitoring plan

Sample Language:

"This patient has stage 3 neurotrophic keratitis of the right eye with a 4mm central corneal ulcer and 60% stromal thinning. Corneal sensation is absent on Cochet-Bonnet testing. Despite 4 weeks of preservative-free carboxymethylcellulose drops every 2 hours and nighttime ointment, the epithelial defect has enlarged and stromal involvement has progressed. Without nerve growth factor therapy, this patient faces imminent corneal perforation requiring emergency surgical intervention."

Appeals Process for Humana in Illinois

Level 1: Internal Appeal (Redetermination)

Deadline: 65 days from denial notice
How to file: Humana member portal, phone, or written request
Timeline: 30 days for medical benefit; 7 days for Part D standard
Include: New medical evidence, detailed rebuttal of denial reasons

Level 2: Independent Review Entity (IRE)

Deadline: 65 days from Level 1 denial
Automatic: For Part D appeals
Timeline: 7 days standard; 72 hours expedited

Illinois External Review (After Medicare Appeals)

For Medicare Advantage plans, after exhausting federal appeals: Deadline: 30 days from final adverse determination
Process: Illinois Health Carrier External Review Act
Contact: Illinois Department of Insurance at (877) 527-9431
Timeline: 45 days maximum for decision

Illinois Advantage: The state's external review process provides an additional layer of protection with independent physician reviewers who specialize in your condition.

Scripts & Templates

Patient Phone Script for Humana

"Hi, I'm calling about a prior authorization denial for Oxervate, generic name cenegermin. My member ID is [ID number]. I have stage [2/3] neurotrophic keratitis and my ophthalmologist says this is the only FDA-approved treatment. Can you tell me specifically what documentation is missing and connect me with someone who can expedite this review? This is a sight-threatening condition."

Peer-to-Peer Request Script for Clinic Staff

"I'm calling to request a peer-to-peer review for [patient name], member ID [number]. We have a denial for Oxervate for neurotrophic keratitis. Dr. [name] is a board-certified ophthalmologist and would like to speak with your medical director about this case. The patient has a progressive corneal ulcer that could perforate without treatment. When can we schedule this call?"

Illinois External Review Process

Illinois provides robust patient protections through the Health Carrier External Review Act. Here's how it works:

Key Timelines:

  • 30 days to request external review after final denial
  • 5 business days for carrier preliminary review
  • 1 business day for IRO assignment
  • 45 days maximum for final decision

Required Forms:

  • External Review Request Form (provided with denial notice)
  • Authorized Representative Form (if applicable)
  • Health Care Provider Certification (for expedited reviews)

Cost:

Free to consumers - Illinois insurers pay all external review costs

Contact Information:

Illinois Department of Insurance
Office of Consumer Health Insurance: (877) 527-9431
Illinois Attorney General Health Care Bureau: (877) 305-5145

Counterforce Health helps patients and clinicians navigate these complex appeal processes by analyzing denial letters and drafting evidence-backed appeals that align with each plan's specific requirements.

Financial Assistance Options

Manufacturer Support

Oxervate Patient Support Program

Foundation Grants

  • Patient Access Network Foundation
  • Good Days Foundation
  • HealthWell Foundation

Medicare Part D 2025 Changes

$2,000 annual out-of-pocket cap - Once you reach $2,000 in covered drug costs, you pay $0 for additional Part D drugs for the rest of the year.

FAQ

How long does Humana prior authorization take for Oxervate?
Standard timeline is 72 hours for Part D drugs. Expedited reviews (when delay could jeopardize health) must be completed within 24 hours.

What if Oxervate is non-formulary on my Humana plan?
You can request a formulary exception. Your doctor must demonstrate medical necessity and that no formulary alternatives are appropriate for your condition.

Can I get expedited approval for Oxervate?
Yes, if your ophthalmologist documents that delay could cause serious harm (e.g., corneal perforation risk). Submit expedited PA request with clinical justification.

Does step therapy apply to Oxervate?
Most plans require documented failure of preservative-free artificial tears and other supportive measures, but specific step therapy requirements vary by plan.

What happens if my appeal is denied in Illinois?
You can request Illinois external review within 30 days. An independent physician reviewer will make a binding decision that Humana must follow.

How much will Oxervate cost with Humana coverage?
As a specialty tier drug, expect high coinsurance until you reach the $2,000 Part D out-of-pocket cap in 2025. Manufacturer assistance may help reduce costs.

When navigating insurance denials for specialized treatments like Oxervate, having expert support can make the difference between approval and denial. Counterforce Health specializes in turning insurance denials into targeted appeals by identifying the specific denial basis and crafting point-by-point rebuttals using the right clinical evidence and payer-specific language.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. For specific questions about your coverage, contact Humana member services directly. For assistance with complex appeals, consider consulting with qualified patient advocates or legal professionals experienced in insurance matters.

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