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Cimzia (certolizumab) — United Healthcare

Plaque Psoriasis

Initial criteria

  • (1) Diagnosis of moderate to severe plaque psoriasis
  • -AND- (2) One of the following:
  • (a) Both of the following:
  • i. Failure, contraindication, or intolerance to TWO of the following topical therapies:
  • • Corticosteroids (e.g., betamethasone, clobetasol, desonide)
  • • Vitamin D analogs (e.g., calcitriol, calcipotriene)
  • • Tazarotene
  • • Calcineurin inhibitors (e.g., tacrolimus, pimecrolimus)
  • • Anthralin
  • • Coal tar
  • -AND- iii. History of failure to a 3-month trial of methotrexate at maximally indicated dose, unless contraindicated or clinically significant adverse effects are experienced (document date and duration of trial)
  • -OR- (b) Patient has been previously treated with a targeted immunomodulator FDA-approved for the treatment of plaque psoriasis as documented by claims history or submission of medical records (document drug, date, and duration of therapy) [e.g., adalimumab, Otezla (apremilast), Skyrizi (risankizumab), Stelara (ustekinumab), Tremfya (guselkumab)]
  • -OR- (c) Both of the following:
  • i. Patient is currently on Cimzia therapy as documented by claims history or submission of medical records (document date and duration of therapy)
  • -AND- ii. Patient has not received a manufacturer supplied sample at no cost in the prescriber’s office, or any form of assistance from the UCB sponsored CIMplicity program as a means to establish as a current user of Cimzia
  • -AND- (3) Patient is not receiving Cimzia in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Simponi (golimumab), Orencia (abatacept), adalimumab, Stelara (ustekinumab), Skyrizi (risankizumab), Tremfya (guselkumab), Cosentyx (secukinumab), Taltz (ixekizumab), Siliq (brodalumab), Ilumya (tildrakizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]
  • -AND- (4) Prescribed by or in consultation with a dermatologist
  • Note: Patients who received a manufacturer sample or assistance must meet initial authorization criteria as if new to therapy
  • State mandates (CT, KY, MS): 30-day methotrexate trial required

Reauthorization criteria

  • (1) Documentation of positive clinical response to Cimzia therapy
  • -AND- (2) Patient is not receiving Cimzia in combination with another targeted immunomodulator [same list as above]

Approval duration

12 months