Cimzia — Cigna
Crohn’s Disease
Preferred products
- adalimumab-adbm
- Cyltezo
- adalimumab-adaz
- adalimumab-ryvk
- Simlandi
- Omvoh subcutaneous
- Skyrizi subcutaneous (on-body injector)
- Stelara subcutaneous
- Imuldosa subcutaneous
- Selarsdi subcutaneous
- ustekinumab-ttwe subcutaneous
- Yesintek subcutaneous
- Tremfya subcutaneous
- Zymfentra
Initial criteria
- Patient meets the standard Inflammatory Conditions – Cimzia Prior Authorization Policy criteria; AND
- Patient meets ONE of the following:
- a) Rheumatoid Arthritis: patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR [documentation required]; OR
- b) Ankylosing Spondylitis: patient has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, or Xeljanz/XR [documentation required]; OR
- c) Juvenile Idiopathic Arthritis: patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq/Rinvoq LQ, and Xeljanz [documentation required]; OR
- d) Psoriatic Arthritis: patient has tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya subcutaneous, or Xeljanz/XR [documentation required]; OR
- e) Plaque Psoriasis: patient has tried TWO of Enbrel, an adalimumab product, Otezla, Skyrizi subcutaneous, Sotyktu, an ustekinumab subcutaneous product, Taltz, or Tremfya subcutaneous [documentation required]; OR
- f) Crohn’s Disease: patient has tried ONE of an adalimumab product, Omvoh subcutaneous, Skyrizi subcutaneous (on-body injector), an ustekinumab subcutaneous product, Tremfya subcutaneous, or Zymfentra; OR
- g) Patient has been established on Cimzia for at least 90 days and prescription claims history indicates at least a 90-day supply of Cimzia was dispensed within the past 130 days [verification in prescription claims history required], or verified by prescriber if claims history unavailable.
Approval duration
1 year