By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by Humana in New York: Appeals, Forms, and Financial Assistance

Answer Box: Getting Oxervate Covered by Humana in New York

Quick Path to Approval: Oxervate (cenegermin) requires prior authorization from Humana and is typically non-formulary or specialty tier. Success depends on documenting stage 2/3 neurotrophic keratitis diagnosis, failed conventional treatments, and corneal nerve damage evidence. If denied, New York residents have 65 days to appeal internally, then can request external review through the NY Department of Financial Services within 4 months.

First Step Today: Contact your ophthalmologist to gather all eye care records, diagnostic test results (Cochet-Bonnet or cotton wisp tests), and documentation of failed lubricants/bandage lenses. Then call Humana at the number on your insurance card to confirm your plan's formulary status for Oxervate and request prior authorization forms.

Table of Contents

  1. Understanding Oxervate Coverage with Humana
  2. Prior Authorization Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Process in New York
  6. Cost Assistance and Financial Support
  7. Working with Specialty Pharmacies
  8. When to Escalate: New York State Resources
  9. FAQ: Humana and Oxervate in New York

Understanding Oxervate Coverage with Humana

Oxervate (cenegermin) is a breakthrough treatment for neurotrophic keratitis, but getting it covered by Humana requires navigating their specialty drug protocols. This recombinant human nerve growth factor costs in the low six figures for an 8-week course, making proper insurance approval essential.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Always required Humana Provider Portal
Formulary Status Often non-formulary or Tier 4 specialty Humana Drug List Tool
Specialty Pharmacy Must use CenterWell or approved network CenterWell Specialty
Appeals Deadline 65 days from denial notice Medicare Appeals Guidelines
External Review 4 months after final denial NY DFS External Appeals
Note: Humana's Medicare Advantage plans follow federal appeal timelines, not New York's standard commercial insurance rules.

Prior Authorization Requirements

Humana requires comprehensive documentation to approve Oxervate. Here's what your ophthalmologist must include:

Medical Necessity Checklist

Diagnosis Documentation:

  • Confirmed stage 2 or 3 neurotrophic keratitis with ICD-10 code H16.23
  • Objective evidence of corneal sensation loss (Cochet-Bonnet or cotton wisp test results)
  • Clinical photographs or fluorescein staining showing corneal defects

Treatment History:

  • Documented failure of conventional therapies including:
    • Preservative-free artificial tears (specific brands and duration tried)
    • Bandage contact lenses (type and outcome)
    • Punctal plugs or tarsorrhaphy (if attempted)
  • Specific reasons why each treatment failed or caused adverse effects

Clinical Rationale:

  • Explanation of why Oxervate is medically necessary
  • Treatment goals and expected outcomes
  • Monitoring plan during 8-week therapy course

Clinician Corner: Medical Necessity Letter

Your ophthalmologist's letter should address these key points:

  • Problem: Specific stage of neurotrophic keratitis and functional impact
  • Prior treatments: Detailed list with dates, outcomes, and reasons for discontinuation
  • Clinical rationale: Why Oxervate is the appropriate next step based on FDA labeling
  • Dosing plan: Standard 1 drop 6 times daily for 8 weeks protocol
  • Monitoring: Follow-up schedule and success metrics

Step-by-Step: Fastest Path to Approval

1. Gather Documentation (Patient + Clinic)

Timeline: 1-2 weeks
Action: Collect all eye care records, diagnostic tests, and treatment history
Submit to: Your ophthalmologist's office

2. Verify Insurance Benefits (Patient)

Timeline: 1-2 business days
Action: Call Humana member services to confirm formulary status
Phone: Number on back of insurance card

3. Complete Prior Authorization (Clinic)

Timeline: 2-3 business days to submit
Action: Submit PA request via Humana Provider Portal
Include: Medical necessity letter, clinical notes, diagnostic results

4. Request Formulary Exception (If Needed)

Timeline: Submit simultaneously with PA
Action: If Oxervate is non-formulary, request exception
Form: Medicare Coverage Determination Request

5. Follow Up (Patient + Clinic)

Timeline: 7-14 days after submission
Action: Check status via provider portal or member services
Escalate: Request expedited review if urgent clinical need

6. Coordinate Specialty Pharmacy (Upon Approval)

Timeline: 1-2 days
Action: Work with CenterWell Specialty Pharmacy for fulfillment
Phone: 1-800-486-2668

7. Apply for Financial Assistance (Patient)

Timeline: Concurrent with approval process
Action: Contact Dompé CONNECT to Care for copay support
Phone: 1-877-422-4412

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient diagnosis documentation Provide objective testing results Cochet-Bonnet test, corneal sensitivity mapping
Inadequate prior therapy trials Document specific treatments tried Pharmacy records, clinical notes with dates/outcomes
Non-formulary status Request formulary exception Prescriber statement on why alternatives unsuitable
Experimental/investigational Cite FDA approval FDA approval letter and labeling
Quantity/duration limits Justify 8-week protocol Clinical literature supporting standard dosing
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps identify the specific denial basis and drafts point-by-point rebuttals aligned to each plan's requirements.

Appeals Process in New York

Internal Appeals (First Level)

Timeline: 65 days from denial notice
Submit to: Humana via fax at 877-486-2621
Required: Completed appeal form, additional medical evidence, prescriber statement

External Review (New York State)

If Humana upholds the denial, New York residents can request external review:

Timeline: 4 months after final internal denial
Submit to: NY Department of Financial Services
Cost: $25 fee (waived for financial hardship or Medicaid)
Decision: Binding on Humana if overturned

Expedited External Appeals: Available for urgent needs with decisions in 72 hours (24 hours for urgent drug denials).

When Federal vs. State Rules Apply

  • Humana Medicare Advantage: Federal appeals only (no NY external review)
  • Humana Commercial Plans: NY external review available after internal appeals
  • Medicaid Managed Care: Choice between DFS external review or state Fair Hearing

Cost Assistance and Financial Support

Manufacturer Programs

Dompé CONNECT to Care Copay Program

  • Eligibility: Commercial insurance only (Medicare patients excluded)
  • Benefit: Reduces out-of-pocket to maximum $100 for 8-week course
  • Apply: Fax enrollment form to 1-855-263-1775
  • Phone: 1-877-422-4412

Patient Assistance Program

  • Eligibility: Uninsured or underinsured patients
  • Benefit: Medication at reduced or no cost based on financial need
  • Apply: Complete enrollment form with income documentation

Foundation Grants

Several organizations provide copay assistance for rare disease medications:

  • PAN Foundation: Disease-specific funds for neurotrophic keratitis (income limit: under $75,300/year for individuals)
  • The Assistance Fund: Call 855-845-3663 for current program availability
  • NORD: Neurotrophic keratitis copay assistance (verify current status)
From our advocates: We've seen patients successfully combine manufacturer copay cards with foundation grants to eliminate out-of-pocket costs entirely. Start applications early since some funds have waiting lists, and always check multiple sources as program availability changes frequently.

New York State Resources

Community Health Advocates (CHA)

Working with Specialty Pharmacies

Oxervate requires specialty pharmacy dispensing through Humana's network:

CenterWell Specialty Pharmacy

  • Phone: 1-800-486-2668
  • Services: Prior authorization support, benefit investigation, home delivery
  • Coordination: Works directly with Humana for coverage verification

Accredo Health Group

  • Alternative: May be used for Oxervate fulfillment in some cases
  • Delivery: Ships directly to patient every two weeks during therapy
  • Support: Coordinates with Dompé CONNECT to Care program

Key Coordination Steps

  1. Confirm network participation before prescription transfer
  2. Verify delivery schedule aligns with 8-week treatment protocol
  3. Coordinate refrigeration requirements (Oxervate must be stored at 36-46°F)
  4. Set up automatic refill reminders

When to Escalate: New York State Resources

File a Complaint with New York Regulators

NY Department of Financial Services

  • Phone: 1-800-342-3736
  • Online: DFS Consumer Portal
  • When to use: Humana fails to respond within required timelines or doesn't follow proper procedures

NY Department of Health (for Medicaid issues)

  • Phone: 1-855-355-2552
  • Services: Medicaid managed care complaints and appeals assistance

New York Legal Aid Society

  • Services: Free legal assistance for insurance coverage disputes
  • Contact: Local offices throughout New York state

FAQ: Humana and Oxervate in New York

Q: How long does Humana take to decide on Oxervate prior authorization? A: Standard decisions take up to 72 hours for Medicare Part D, up to 30 days for Medicare Advantage. Expedited reviews are available in 24 hours for urgent cases.

Q: What if Oxervate isn't on my Humana formulary? A: Request a formulary exception simultaneously with your prior authorization. Your prescriber must explain why covered alternatives aren't suitable.

Q: Can I appeal a Humana denial if I live in New York? A: Yes. Medicare Advantage uses federal appeals (65-day deadline), while commercial plans can use NY external review after internal appeals are exhausted.

Q: Does step therapy apply to Oxervate? A: Humana typically requires documentation of failed conventional treatments (lubricants, bandage lenses) before approving Oxervate, which functions similarly to step therapy.

Q: What's the difference between internal and external appeals in New York? A: Internal appeals are with Humana directly. External appeals go through NY Department of Financial Services with independent medical experts making binding decisions.

Q: Can I use manufacturer copay cards with Medicare? A: No, federal law prohibits manufacturer copay cards for Medicare beneficiaries. However, you may qualify for Dompé's patient assistance program based on financial need.

Q: How do I expedite an appeal for urgent medical need? A: Contact Humana member services and request expedited review, providing medical documentation of urgent clinical need. NY external appeals can also be expedited.

Q: What happens if my 8-week Oxervate course needs to be repeated? A: Re-treatment requires new prior authorization with clinical justification for why additional therapy is necessary based on treatment response.

At Counterforce Health, we understand that navigating insurance approvals for specialty medications like Oxervate can feel overwhelming. Our platform helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by identifying specific denial reasons and crafting evidence-backed responses aligned to each plan's requirements. We pull the right clinical citations and weave them into appeals that meet procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies and appeal procedures may change. Always verify current requirements with your insurance plan and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting with qualified patient advocates or legal professionals.

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