Cimzia — Medical Mutual
Spondyloarthritis, Other Subtypes (e.g., undifferentiated arthritis, reactive arthritis)
Initial criteria
- Patient age ≥ 18 years
- Patient has arthritis primarily in knees, ankles, elbows, wrists, hands, and/or feet
- Patient has tried ≥ 1 conventional synthetic DMARD (e.g., methotrexate, leflunomide, sulfasalazine)
- Medication is prescribed by or in consultation with a rheumatologist
- 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 beneficial clinical response (e.g., ASDAS, CRP, ESR) OR Compared with baseline, patient experienced symptom improvement (e.g., less pain, stiffness, improved function, ADLs)
- Site of care medical necessity is met
Approval duration
initial 6 months, reauth 1 year