Cimzia — Medica

Plaque Psoriasis

Initial criteria

Patient meets the standard Inflammatory Conditions – Cimzia Prior Authorization Policy criteria
AND for Psoriatic Arthritis: patient has tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya subcutaneous, and Xeljanz/XR
OR for Plaque Psoriasis: patient has tried TWO of Enbrel, an adalimumab product, Otezla, Skyrizi subcutaneous, Sotyktu, an ustekinumab subcutaneous product, Taltz, and Tremfya subcutaneous
OR for 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

Approve if patient continues therapy and met initial criteria or has been established on Cimzia for at least 90 days with claim history verification

6 months