Cimzia — Medical Mutual

Initial criteria

• Patient age ≥ 18 years
• Patient has tried or is currently taking corticosteroids OR corticosteroids are contraindicated OR patient has tried one other conventional systemic agent for Crohn’s disease (e.g., azathioprine, 6-mercaptopurine, methotrexate) OR patient has tried a biologic other than Cimzia OR patient has enterocutaneous or rectovaginal fistulas OR patient had ileocolonic resection
• Cimzia is prescribed by or in consultation with a gastroenterologist
• Site of care medical necessity is met

Reauthorization criteria

• Patient has been established on therapy for ≥ 6 months
• When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (e.g., fecal markers, serum markers, imaging, endoscopy, reduced corticosteroid use) OR Compared with baseline, patient experienced symptom improvement (e.g., decreased pain, fatigue, stool frequency, stool in blood)
• Site of care medical necessity is met

Approval duration

initial 6 months, reauth 1 year