Cimzia SQ
Pharmacy prior authorization/step-edit form and clinical criteria for coverage of Cimzia (certolizumab) subcutaneous across multiple labeled indications; specifies required prior therapies, prescriber specialty, documentation, and specialty pharmacy provision. It also states that concomitant biologic immunomodulators are not permitted.
No material clinical or coverage changes
Coverage Summary
This policy is a pharmacy prior authorization/step-edit for Cimzia® SQ (certolizumab) that is covered with criteria across multiple labeled indications and requires submission of the form with prescriber signature and supporting documentation. The request must be completed and faxed with required labs, diagnostics, and chart notes (per prescriber signature and documentation requirements), dispensing is handled by the specialty pharmacy Proprium Rx, and use of samples to initiate therapy does not meet step edit/preauthorization criteria.