CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Oxervate (cenegermin-bkbj)

Coverage policy for Oxervate (cenegermin-bkbj) for members (Medicaid scope) specifying clinical criteria for approval, quantity limits, and duration for treatment of persistent epithelial defects/corneal ulceration related to neurotrophic keratitis.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOxervate (cenegermin-bkbj)

Policy CodePolicy N/A

Change Typeclarified

Effective DateMay 1, 2019

Next Review Date

Key ActionAuthorization of 8 weeks may be granted only when all documented clinical criteria are met; provider must document age ≥2 years, prescriber specialty, refractory PED/corneal ulcer ≥2 weeks, decreased corneal sensitivity in at least one corneal quadrant, no prior Oxervate in affected eye, technique counseling, and confirmation of sufficient dexterity.

SourceLink

POLICY UPDATE CHANGES

Reviewed on 3/2026 with no material clinical policy statement changes indicated in document header.

8 weeksCoverage Duration

28 vialsQty per 28 days (one eye)

56 vialsQty per 28 days (both eyes)

≥2 yrsMinimum Age

Scope: Coverage policy for Oxervate (cenegermin-bkbj) for members (Medicaid scope) for treatment of neurotrophic keratitis presenting as persistent epithelial defects (PED) or corneal ulceration. Coverage stance: covered_with_criteria. Product indication: Oxervate is indicated for neurotrophic keratitis presenting as persistent epithelial defects or corneal ulceration. Coverage duration: 8 weeks. Quantity limits: 28 vials per 28 days for one eye and 56 vials per 28 days if both eyes are affected. Minimum age for authorization: >=2 years. Policy effective date: 05/01/2019; last review: 03/01/2026.

OpenPayer

Oxervate (cenegermin-bkbj)

Coverage Summary