Cimzia (certolizumab) — United Healthcare

Rheumatoid Arthritis

Initial criteria

Diagnosis of moderately to severely active rheumatoid arthritis
AND one of the following:
- History of failure to a 3 month trial of one non-biologic DMARD [e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine] at maximally indicated doses, unless contraindicated or clinically significant adverse effects are experienced (document drug, date, and duration)
OR patient has been previously treated with a targeted immunomodulator FDA-approved for rheumatoid arthritis (e.g., Enbrel, Simponi, Orencia, adalimumab, Xeljanz, Olumiant, 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

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]

12 months