Cimzia (certolizumab) — United Healthcare

Initial criteria

• Diagnosis of active ankylosing spondylitis or non-radiographic axial spondyloarthritis
• AND one of the following:
• - History of failure to two NSAIDs (e.g., ibuprofen, naproxen) at maximally indicated doses, each used for at least 4 weeks, unless contraindicated or clinically significant adverse effects are experienced (document drug, date, and duration of trials)
• OR patient has been previously treated with a targeted immunomodulator FDA-approved for ankylosing spondylitis (e.g., adalimumab, Simponi, Xeljanz/Xeljanz XR, Rinvoq) 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 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, Simponi, Orencia, adalimumab, Xeljanz, Olumiant, Rinvoq]
• AND prescribed by or in consultation with a rheumatologist

Reauthorization criteria

• 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]

Approval duration

12 months