Cimzia — Medica
Other Conditions
Preferred products
- Humira
- Amjevita
- Skyrizi subcutaneous [on-body injector]
- Stelara subcutaneous
Initial criteria
- Patient meets the standard Inflammatory Conditions – Cimzia Prior Authorization Policy criteria
Reauthorization criteria
- Patient meets BOTH of the following (i and ii):
- i. Patient meets the standard Inflammatory Conditions – Cimzia Prior Authorization Policy criteria; AND
- ii. Patient meets ONE of the following conditions (a–f):
- a) Rheumatoid Arthritis: tried TWO of Actemra subcutaneous, Enbrel, an adalimumab product (Humira, Amjevita), Rinvoq, and Xeljanz/XR [documentation required]; OR
- b) Ankylosing Spondylitis: tried TWO of Enbrel, an adalimumab product (Humira, Amjevita), Rinvoq, Taltz, and Xeljanz/XR [documentation required]; OR
- c) Psoriatic Arthritis: tried TWO of Enbrel, an adalimumab product (Humira, Amjevita), Otezla, Rinvoq, Skyrizi subcutaneous, Stelara subcutaneous, Taltz, Tremfya, and Xeljanz/XR [documentation required]; OR
- d) Plaque Psoriasis: tried TWO of Enbrel, an adalimumab product (Humira, Amjevita), Otezla, Skyrizi subcutaneous, Stelara subcutaneous, Taltz, and Tremfya [documentation required]; OR
- e) Crohn’s Disease: tried one adalimumab product (Humira, Amjevita); OR
- f) Patient has been established on Cimzia for at least 90 days with a paid prescription claims history indicating a ≥90-day supply within the past 130 days or prescriber verification.
Approval duration
1 year