By Counterforce Health Team in Oxervate (cenegermin) —

How to Get Oxervate (Cenegermin) Covered by UnitedHealthcare in New Jersey: Complete Prior Authorization & Appeal Guide

Answer Box: Getting Oxervate Covered by UnitedHealthcare in New Jersey

Oxervate requires prior authorization from UnitedHealthcare with strict medical necessity criteria. You'll need confirmed Stage 2 or 3 neurotrophic keratitis, documented failure of at least one over-the-counter artificial tear, and prescribing by an ophthalmologist. Submit through the UnitedHealthcare Provider Portal with complete clinical documentation. If denied, New Jersey offers robust appeal rights including external review through the Independent Health Care Appeals Program (IHCAP). Start today: Gather your diagnosis staging documentation and artificial tear trial records.

Table of Contents

  1. UnitedHealthcare Plan Types & Coverage Implications
  2. Oxervate Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network & Dispensing
  5. Cost-Share Basics
  6. Submission Process & Required Documentation
  7. Common Approval Patterns
  8. Appeals Process in New Jersey
  9. Verification Resources
  10. FAQ

UnitedHealthcare Plan Types & Coverage Implications

UnitedHealthcare offers several plan types in New Jersey, each with different coverage rules for specialty medications like Oxervate:

Commercial Plans (HMO/PPO/EPO)

  • All require prior authorization for Oxervate
  • HMO plans may require ophthalmology referrals
  • Network restrictions apply for both prescribing and dispensing

Medicare Advantage

Medicaid (NJ FamilyCare)

  • Follows New Jersey Medicaid formulary rules
  • May have additional state-specific requirements
  • External appeals through IHCAP available
Note: Self-funded employer plans follow federal ERISA rules, not New Jersey insurance law, which affects your appeal rights.

Oxervate Formulary Status & Tier Placement

Current Status (2024): Oxervate is covered under UnitedHealthcare/OptumRx plans as a specialty or non-preferred brand drug, requiring the highest copayment tier.

Coverage Details

  • Prior Authorization: Required for all plans
  • Formulary Tier: Specialty/Non-preferred brand (highest cost-sharing)
  • Supply Limits: Standard 56 vials (8-week course)
  • Dispensing: Through Accredo Health Group (UnitedHealthcare's preferred specialty pharmacy)

Alternative Treatments

Before approving Oxervate, UnitedHealthcare may require trials of:

  • Over-the-counter artificial tears (Systane Ultra, Refresh Optive, Soothe XP)
  • Autologous serum eye drops
  • Therapeutic contact lenses
  • Amniotic membrane transplantation

Prior Authorization Requirements

UnitedHealthcare requires comprehensive documentation for Oxervate approval:

Medical Necessity Criteria

  1. Confirmed diagnosis of Stage 2 or 3 neurotrophic keratitis
  2. Failed therapy with at least one over-the-counter artificial tear product
  3. Prescriber qualification: Ophthalmologist or optometrist
  4. Proper staging documentation with clinical findings

Required Documentation

  • Slit-lamp examination findings
  • Corneal sensitivity testing results
  • Photographic evidence of epithelial defects or ulceration
  • Documentation of failed artificial tear trials (dates, products, outcomes)
  • ICD-10 codes: H16.231–H16.233
  • NDC code: 71923-019-01
Clinician Corner: Your medical necessity letter should address the specific denial reasons in UnitedHealthcare's policy. Include objective corneal sensitivity measurements and clear documentation of epithelial defect persistence despite standard care.

Specialty Pharmacy Network & Dispensing

Oxervate is dispensed exclusively through Accredo Health Group under UnitedHealthcare plans, not through CVS Specialty or retail pharmacies.

Dispensing Process

  1. Prescription sent to Accredo after PA approval
  2. Patient enrollment in Dompé CONNECT to Care program
  3. Home delivery every two weeks during 8-week treatment
  4. Cold-chain shipping with temperature monitoring

Patient Setup Steps

  • Insurance verification through Accredo
  • Copay assistance enrollment (if eligible)
  • Delivery scheduling and storage education
  • Clinical support throughout treatment

Cost-Share Basics

Oxervate typically costs in the low six figures for an 8-week course. Your out-of-pocket costs depend on your specific UnitedHealthcare plan design:

Typical Cost Structure

  • Deductible: May apply before coverage begins
  • Coinsurance: Often 20-40% for specialty tier drugs
  • Copay: Fixed amount (varies by plan)
  • Out-of-pocket maximum: Annual limit on your costs

Financial Assistance Options

  • Manufacturer support: Dompé CONNECT to Care program
  • Foundation grants: Available for qualifying patients
  • State programs: New Jersey may offer additional assistance

This is educational information only. Consult your plan documents for specific cost-sharing details.

Submission Process & Required Documentation

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Complete ophthalmology records
    • Corneal sensitivity testing results
    • Photos of epithelial defects
    • Failed treatment history
  2. Submit Prior Authorization (Prescriber)
  3. Track Status (Clinic Staff)
    • Monitor portal for updates
    • Respond promptly to information requests
    • Prepare for potential peer-to-peer review
  4. Handle Approval (Patient/Clinic)
    • Prescription routed to Accredo
    • Patient enrollment initiated
    • First shipment scheduled

Required Forms and Codes

  • ICD-10: H16.231 (unilateral), H16.232 (bilateral), H16.233 (unspecified)
  • NDC: 71923-019-01
  • HCPCS: J3590 (for medical benefit billing)

Common Approval Patterns

Successful Oxervate approvals typically include:

Strong Documentation Elements

  • Objective staging: Clear slit-lamp findings with measurements
  • Corneal sensitivity data: Quantitative testing results when possible
  • Treatment timeline: Detailed history of failed conventional therapies
  • Photography: Visual evidence of persistent epithelial defects
  • Specialist consultation: Ophthalmology evaluation and ongoing care plan

Red Flags That Trigger Denials

  • Missing corneal sensitivity testing
  • Inadequate documentation of artificial tear failures
  • Unclear staging (Stage 1 vs. Stage 2/3)
  • Prescribing outside ophthalmology specialty

Appeals Process in New Jersey

If UnitedHealthcare denies your Oxervate request, New Jersey offers excellent appeal protections:

Internal Appeals (UnitedHealthcare)

  1. File within 180 days of denial
  2. Submit via: Phone, fax, or online portal
  3. Timeline: 30 days for standard review, 72 hours for expedited
  4. Required: Complete medical records and physician letter

External Review (New Jersey IHCAP)

After exhausting internal appeals, you can request an independent review:

  1. File with: New Jersey Department of Banking and Insurance
  2. Timeline: 4 months from final internal denial
  3. Process: Independent physician reviewers evaluate your case
  4. Cost: Free to patients
  5. Decision: Binding on UnitedHealthcare if overturned
From Our Advocates: We've seen cases where thorough documentation of corneal sensitivity loss and failed artificial tear trials significantly improved external review outcomes. The key is presenting clear evidence that Oxervate addresses an unmet medical need that conventional treatments cannot resolve.

Appeal Success Factors

  • Complete clinical documentation
  • Clear medical necessity argument
  • Evidence of treatment failures
  • Specialist support letter
  • Timely submission

Verification Resources

Always verify current information through official sources:

UnitedHealthcare Resources

  • Provider Portal: uhcprovider.com
  • Member Services: Phone number on your insurance card
  • Prior Auth Policies: Available through provider portal
  • Formulary Lookup: OptumRx formulary search tool

New Jersey Resources

  • DOBI Consumer Hotline: 1-800-446-7467
  • IHCAP Information: 1-888-393-1062
  • External Review Forms: NJ DOBI website

Manufacturer Resources

  • Oxervate Information: oxervate.com
  • Patient Support: Dompé CONNECT to Care program
  • Clinical Resources: Available for healthcare providers

For specialized assistance with complex appeals and documentation, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to each plan's specific rules.

FAQ

How long does UnitedHealthcare prior authorization take for Oxervate? Standard review takes up to 72 hours. Expedited review (for urgent cases) takes up to 24 hours.

What if Oxervate is non-formulary on my plan? Oxervate is typically covered but on the highest cost-sharing tier. You can request formulary exceptions with strong medical necessity documentation.

Can I request an expedited appeal in New Jersey? Yes, both UnitedHealthcare internal appeals and New Jersey external reviews offer expedited processes for urgent medical situations.

Does step therapy apply if I tried treatments outside New Jersey? Yes, documented treatment failures from other states typically count toward step therapy requirements if properly documented.

What happens if I'm denied after external review? External review decisions are binding. However, you may have additional rights under federal law if you have an ERISA plan.

How much will Oxervate cost me? Costs vary by plan design. Contact UnitedHealthcare member services and explore manufacturer assistance programs for specific estimates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan documents for personalized guidance. Coverage policies and procedures may change. Verify all information with official sources before making healthcare decisions.

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