Cimzia (certolizumab) — United Healthcare

Crohn’s Disease

Initial criteria

Diagnosis of moderately to severely active Crohn’s disease
AND one of the following:
- History of failure to one of the following conventional therapies at maximally indicated doses, unless contraindicated or clinically significant adverse effects are experienced (document drug, date, and duration of trial): corticosteroids (e.g., prednisone, methylprednisolone, budesonide), 6-mercaptopurine (Purinethol), azathioprine (Imuran), or methotrexate (Rheumatrex, Trexall)
OR patient has been previously treated with a targeted immunomodulator FDA-approved for the treatment of Crohn’s disease (e.g., adalimumab, Stelara [ustekinumab], Skyrizi [risankizumab]) as documented by claims history or medical records
OR both of the following: patient is currently on Cimzia therapy (document date and duration) AND patient has not received a manufacturer supplied sample or CIMplicity program assistance to establish as a current user
AND patient is not receiving Cimzia in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Simponi (golimumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Stelara (ustekinumab), Skyrizi (risankizumab)]
AND prescribed by or in consultation with a gastroenterologist

Documentation of positive clinical response to Cimzia therapy
AND patient is not receiving Cimzia in combination with another targeted immunomodulator [e.g., Enbrel, Simponi, Orencia, adalimumab, Xeljanz, Olumiant, Rinvoq, Stelara, Skyrizi]

12 months