Subject: Specialty Quantity Limit Oxervate 3365-H P2025

Drug

OXERVATE  (cenegermin-bkbj)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for the FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Oxervate 0.002% ophthalmic solution,   carton containing 7 vials (1 mL in each vial)	16 cartons (112 mL) per 56 days

FDA-recommended Dosing

One drop in the affected eye(s), 6 times per day at 2-hour intervals, for eight weeks (requiring one vial per day per eye)

Place of Service:

Outpatient

The above policy is based on the following references:

1. Oxervate [package insert]. San Mateo, CA: Dompe U.S. Inc.; February 2025.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

February 15, 2026