CurrentCignaPolicy N/A

Cigna National Formulary Coverage - Inflammatory Conditions Preferred Specialty Management Policy

Defines preferred vs non-preferred specialty products and step/exception criteria for inflammatory conditions across Cigna National Preferred and Basic Formularies; requires meeting standard prior authorization policies and documented trials of preferred or directed products before coverage of non-preferred products.

Policy Summary

PayerCigna

PolicyCigna National Formulary Coverage - Inflammatory Conditions Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypePreferred product list updates; additions and removals

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProviders must demonstrate the patient meets the relevant standard Inflammatory Conditions prior authorization policy criteria for the requested product and submit documentation of prior trials when required.

POLICY UPDATE CHANGES

Humira (NDCs starting with 00074) and Hyrimoz (NDCs starting with 61314) were removed from Preferred Products across many indications; previous trials of these NDCs still count toward adalimumab trials.

Tremfya subcutaneous and Omvoh subcutaneous were added as Preferred Products for Ulcerative Colitis and Crohn's Disease in various revisions.

Cimzia was added to Step 3a for Juvenile Idiopathic Arthritis and as an agent that counts toward a Preferred Product trial in multiple indications.

Adalimumab-ryvk NDCs starting with 82009 specified as Preferred product.

Velsipity and other agents (e.g., Imuldosa, Selarsdi, ustekinumab-ttwe, Yesintek) were added as Preferred products for specific indications.

multi-indicationIndications covered (RA, AS, JIA, PsA, Psoriasis, CD, UC, HS)

step-basedStep therapy structure

90/130Continuation verification rule (days)

3/6/12Common approval durations

2Typical required prior-agent trials

SeveralIndications with Preferred-product changes

Coverage Summary & Scope

This policy defines Preferred versus Non‑Preferred specialty products across inflammatory conditions (rheumatology, dermatology, gastroenterology) and requires that patients meet the respective product‑specific standard prior authorization policy criteria before coverage. Covered indications include rheumatoid arthritis (RA), ankylosing spondylitis (AS), juvenile idiopathic arthritis (JIA), psoriatic arthritis (PsA), plaque psoriasis, Crohn's disease (CD), ulcerative colitis (UC), and hidradenitis suppurativa (HS). For Non‑Preferred products the policy applies step therapy and exception criteria that reference trials of Preferred Products or other directed trials; product‑specific standard prior authorization policies remain the controlling criteria for clinical eligibility and should be followed in conjunction with this formulary step policy.

Program-wide Requirements

Program-wide requirements

Covered when ALL of the following program-wide requirements are met:

ALL of the following

Patient meets the respective standard product-specific Prior Authorization (PA) criteria as documented in the applicable standard Prior Authorization Policy.
Trial(s) of Preferred product(s) have been completed as required by the product-specific criteria, when clinically appropriate, prior to approval of Non-Preferred Products. Documentation of trials must be provided when noted as [documentation required].
Continuation of therapy for a patient currently receiving a Non-Preferred subcutaneous or oral product must be supported with verification as indicated in the product-specific criteria: either [verification in prescription claims history required] or, if claims history is unavailable, [verification by prescriber required].
Verification rules
- If at least 130 days of the patient’s prescription claims history is available, claims history must document that the patient received the Non-Preferred Product for the specified period (typically 90 or 120 days) within a 130-day look-back period.
- If 130 days of prescription claims history is unavailable, the prescriber must verify the patient has been receiving the Non-Preferred Product for the required period (typically 90 or 120 days) and that treatment was via paid claims (i.e., not via samples, coupons, or other waivers).
All approvals for continuation of therapy (Preferred and Non-Preferred products) are authorized for 1 year unless otherwise noted. When initial approvals are provided in months, 1 month = 30 days.
When documentation is required, the prescriber must provide written documentation supporting trials of other products (e.g., chart notes, prescription claims records, prescription receipts). Documentation must include patient identifying information.
Consolidated indication-specific trial and continuation rules (applies in addition to the above)
- Rheumatoid Arthritis (RA) — Initial Therapy: Patient must have trialed at least one Step 1 Preferred rheumatology product (eg, Enbrel or a Preferred adalimumab product) unless contraindicated; product-specific criteria may direct trials to a particular Step 1 agent. If a Step 1 trial requirement is not met, approval may be allowed only if the patient has contraindication/intolerance to the Step 1 products with supporting documentation. [documentation required]
- Psoriatic Arthritis — Initial Therapy (Simponi subcutaneous): Approval requires meeting standard RA/PsA initial therapy rules and trial of Step 1 Preferred products; if additional trial of an adalimumab product is required per table, that trial must be documented. If standard criteria are met but the additional directed trial is not met, consider approval only with documented contraindication/intolerance or failure of the directed product. [documentation required]
- Simponi subcutaneous — Current User Continuation: For patients currently receiving Simponi (golimumab) subcutaneous, continuation requires verification in claims history of at least the specified treatment duration (typically 90 days within a 130-day look-back) OR prescriber verification when claims are unavailable. Other clinical continuation requirements in the agent-specific criteria must be met. Approval duration = 1 year unless noted otherwise.

Step Therapy: Preferred (Step 1) vs Non-Preferred (Steps 2/3)

Preferred vs Non-Preferred Step Therapy Table (Rheumatology)

Step 1 = Preferred Products; Step 2a/2b/3a/3b = Non-Preferred directed to specific Step 1/2 products; trials of multiple products within a class count as one trial where noted.

Step 1 Preferred (RA, JIA, AS, nr-axSpA, PsA): Enbrel; Adalimumab products (adalimumab-adbm, adalimumab-adaz, adalimumab-ryvk, Simlandi) — note: multiple adalimumab products count as ONE Preferred Product; NDCs for adalimumab-ryvk start with 82009; Taltz (some indications); Cimzia (nr-axSpA in some instances); Otezla/Otezla XR; Skyrizi SC; Ustekinumab SC products (Imuldosa, Selarsdi, ustekinumab-ttwe, Yesintek); Tremfya SC and others as listed per indication.
Step 2a Non-Preferred (directed to ONE Step 1 Product) examples: Tocilizumab SC products (Tyenne SC) directed to adalimumab specifically; Rinvoq; Xeljanz (tablets/XR) directed to specific Step 1 products as listed per indication.
Step 2b Non-Preferred examples:

Medical-Necessity Criteria — Initial & Continuation (by agent/indication)

Non-Preferred Product Exception Criteria (example: Cimzia)

Non-preferred product is covered as medically necessary only when specified exception criteria are met for each indication; otherwise considered not medically necessary.

Cimzia - Indication-specific exception criteria

Rheumatoid Arthritis - Initial Therapy: Approve for 6 months if BOTH met: (i) patient meets standard Inflammatory Conditions - Cimzia PA Policy criteria; AND (ii) patient has tried TWO of a tocilizumab SC product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR.2 prior products
Documentation required; trials of multiple tocilizumab or adalimumab products count as ONE; Xeljanz products collectively count as ONE.
RA - Alternative when trials not met: If standard Cimzia PA met but prior-trial requirement not met: offer review for Step 1 or Step 2a Product lists (Tyenne SC, Enbrel, adalimumab-adbm/adaz/ryvk [NDCs starting with 82009], Simlandi, Rinvoq, Xeljanz) using respective PA criteria.

Formulary Status, Indication Mappings & Exception Pathways

The policy includes formulary status entries and indication mappings using symbols in the code table. Symbols are defined as: √ indicates the product is designated as preferred/covered for that indication; -- indicates not preferred or not listed for that indication; # is a footnote denoting indicated in polyarticular JIA or other footnote uses per table; and ¥ indicates maintenance dosing only (table footnotes vary by product). Mapping is indication‑specific and presented as table entries in the policy, with additional footnotes and NDC‑specific notes provided where applicable.

Named products (no CPT/HCPCS codes provided in this part)mixed

adalimumab-adbm	adalimumab-adbm subcutaneous injection (Boehringer Ingelheim)
adalimumab-adaz	adalimumab-adaz subcutaneous injection (Sandoz/Novartis)
adalimumab-ryvk	adalimumab-ryvk subcutaneous injection (Quallent/Teva) / Simlandi
Cimzia	certolizumab pegol subcutaneous injection (UCB)
Enbrel	etanercept subcutaneous injection (Amgen)
Simponi	golimumab subcutaneous injection (Janssen)
Zymfentra	infliximab-dyyb subcutaneous injection (Celltrion)
Actemra	tocilizumab subcutaneous injection (Genentech/Roche)
Tyenne	tocilizumab-aazg subcutaneous injection (Fresenius Kabi)
Kevzara	sarilumab subcutaneous injection (Regeneron)

1–10 of 29

1/3

Adalimumab product examples (mentioned as counting trials)mixed

Humira	adalimumab (brand example listed)
Abrilada	adalimumab biosimilar/example
adalimumab-aacf	adalimumab biosimilar NDC/product code name
adalimumab-adaz	adalimumab biosimilar
adalimumab-adbm	adalimumab biosimilar
adalimumab-fkjp	adalimumab biosimilar
adalimumab-aaty	adalimumab biosimilar
adalimumab-ryvk	adalimumab biosimilar (NDCs starting with 82009 referenced)
Simlandi	adalimumab product example
Amjevita	adalimumab product example

1–10 of 17

1/2

Specific agents covered per sectionsmixed

Simponi subcutaneous	golimumab subcutaneous (policy criteria referenced)
Simponi Aria	golimumab intravenous formulation
Actemra subcutaneous	tocilizumab subcutaneous
Tyenne subcutaneous	tocilizumab alternative product referenced
Kevzara	sarilumab (prior authorization criteria referenced)
Zymfentra	product with own prior authorization policy
Bimzelx	biologic IL-17 blocker (bimekizumab)
Cosentyx SC	secukinumab subcutaneous
Cimzia	certolizumab pegol (counts as trial in some rules)
Taltz	ixekizumab

1–10 of 19

1/2

NDC examples of preferred adalimumab productsNDCCovered

82009*

NDCs starting with 82009 (adalimumab-ryvk) noted as Preferred product example

Removed-from-Preferred NDC prefixes (not preferred but prior trial counts)NDC

00074*	Humira NDCs starting with 00074 removed from Preferred Products; previous trials count toward adalimumab trial
61314*	Hyrimoz NDCs starting with 61314 removed from Preferred Products; previous trials count toward adalimumab trial

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required per Standard Drug-Specific PA Criteria

Prior authorization is required. All requests must meet the referenced standard drug-specific prior authorization criteria (see related standard Prior Authorization Policies). Providers should refer to the individual product-specific PA policies for agent-level requirements and submit the required PA form or electronic prior authorization data.

Apply the product-specific PA criteria for the requested agent
Include completed PA form or equivalent electronic prior authorization data

Documentation Required

Document trials of preferred products

Document trials of preferred products when clinically appropriate. Documentation must demonstrate the specific agents tried, dates of trial, dose, duration, and reason for discontinuation or intolerance. Acceptable documentation includes chart notes, prescription claims records, and prescription receipts; all documentation must include patient identifiers.

Definitions & Terminology

Step 1: Preferred products that should be tried first for a given indication.

Step 2a/2b/3a/3b: Non‑Preferred products directed to trials of one or two Step 1 or 2 products; some steps require documentation.

Documentation required: Written documentation (e.g., chart notes, prescription claims records, receipts) supporting prior trials and including patient identifiers.

Trial counts: A trial of multiple products of the same biologic (e.g., multiple adalimumab products or multiple ustekinumab products) counts as ONE product for meeting prior trial requirements.

Established on agent: Patient has been receiving the agent for at least 90 days; verification via prescription claims or prescriber attestation when claims unavailable.

Counts as ONE product: Trials of multiple products within the same drug class (e.g., multiple tocilizumab products, multiple adalimumab products, or both Rinvoq products collectively) count as a single prior product trial.

Preferred Product: Agents designated by the formulary as preferred for a given indication/step; specific NDC prefixes may be used to identify preferred biosimilars (e.g., NDCs starting with 82009 for adalimumab‑ryvk).

√: Formulary designation indicating preferred/covered status (table interpretation).

--: Formulary designation indicating not preferred or not listed for that indication.

# : Footnote indicating 'Indicated in polyarticular JIA' (table footnote use).

¥ : Footnote indicating 'Maintenance dosing only' (table footnote use).

Revision History

2025-01-01formulary_update

Material: Humira (NDCs starting with 00074) and Hyrimoz (NDCs starting with 61314) removed from Preferred Products throughout the policy; prior trials of these NDCs still count toward an adalimumab product trial.

2025-01-01formulary_update

Material: Velsipity added as a Preferred Product for Ulcerative Colitis (effective 01/01/2025).

2025-01-01formulary_update

Material: Tremfya subcutaneous and Omvoh subcutaneous added/moved to Preferred (Step 1) for Ulcerative Colitis and Crohn's Disease in various agent-specific criteria and tables.

Policy Summary

PayerCigna

PolicyCigna National Formulary Coverage - Inflammatory Conditions Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypePreferred product list updates; additions and removals

Effective DateJan 1, 2026

Next Review DateN/A

On This Page

Simponi subcutaneous — If standard criteria met but additional trial requirement not met: If all program and product-specific standard criteria are met but a directed trial of a Preferred product (eg, a specific adalimumab product) was not completed, approval may be granted only if the prescriber documents a contraindication/intolerance to the directed product or documents clinical failure. [documentation required]

Actemra (tocilizumab) subcutaneous — Initial Therapy (Polyarticular Juvenile Idiopathic Arthritis / Rheumatoid Arthritis / other labeled indications): Patient must meet the product-specific PA criteria and must have trialed the required Step 1 Preferred products unless clinically contraindicated. If the standard criteria are met but a directed trial (for example one of the Step 1 products) is not completed, the prescriber must provide documentation of contraindication/intolerance or prior failure. For juvenile indications, follow JIA-specific Step therapy directions (including preferred agents for JIA). [documentation required]

Actemra subcutaneous — If standard criteria met but additional trial requirement not met: Approval may be allowed only with prescriber documentation of contraindication/intolerance or documented failure of the directed product. [documentation required]

Actemra and Kevzara (sarilumab) — Continuation therapy: Continuation requires verification (claims or prescriber) of prior use for the specified duration and meeting clinical response/monitoring criteria as noted in the agent-specific sections. Approvals typically 1 year.

Bimzelx (bimekizumab) — Initial Therapy (Ankylosing Spondylitis, Hidradenitis Suppurativa, non-radiographic axial spondyloarthritis, Plaque Psoriasis, Psoriatic Arthritis): Patient must meet indication-specific criteria and have trialed required Preferred products where directed. If a directed Preferred trial is required but not completed, prescriber must document contraindication/intolerance or prior therapeutic failure. [documentation required]

Bimzelx — Current User Continuation: For patients currently receiving Bimzelx, continuation requires verification via claims history or prescriber attestation per program rules and meeting ongoing clinical criteria. Approvals typically 1 year.

Bimzelx — If standard criteria met but additional trial requirement not met: Prescriber must supply documentation of contraindication/intolerance or failure of directed Preferred agents for approval to be granted. [documentation required]

Cosentyx (secukinumab) subcutaneous — Multiple indications (Ankylosing Spondylitis, non-radiographic axSpA, Plaque Psoriasis): Patient must meet indication-specific PA criteria and directed Step 1 Preferred trials where applicable; if additional trial requirements are not met, documented contraindication/intolerance or prior failure to the directed product must be provided. [documentation required]

Taltz, Ilumya, Omvoh, Skyrizi, Tremfya, Imuldosa, Selarsdi — General: These IL-17/IL-23/IL-12-23 agents follow the program-wide rules and their agent-specific PA criteria, including required trials of Step 1 Preferred agents where indicated. If partial criteria are met but a directed trial is missing, prescriber documentation of contraindication/intolerance or prior failure is required. [documentation required]

Orencia (abatacept) subcutaneous — Approvals and Substitution Offers: When Orencia is requested for a labeled rheumatologic indication, approval follows product-specific PA criteria; if partial step-therapy criteria are met such that alternative Preferred agents remain appropriate, the plan may require substitution to a Preferred product unless prescriber documents contraindication/intolerance or prior failure. [documentation required]

Rinvoq (upadacitinib) and Rinvoq LQ — Multiple Indications: Approvals are contingent on meeting product-specific PA criteria and Step 1 Preferred trials as directed by the rheumatology indication mapping. Where the program directs a trial of a specific Step 1 product (eg, Enbrel or adalimumab), that trial must be documented or a contraindication/intolerance provided. Continuation follows standard verification rules. [documentation required]

Xeljanz (tofacitinib) products — Multiple Indications: Approvals for Xeljanz tablets, XR, or oral solution require meeting product-specific PA criteria and directed Step 1 Preferred trials when indicated. For continuation approvals in Psoriatic Arthritis or Juvenile Idiopathic Arthritis, verify prior use per claims or prescriber attestation and clinical response criteria. If criteria are partially met, the plan may require the prescriber to offer alternate Preferred products when appropriate; documentation of contraindication/intolerance or failure of Preferred alternatives is required for approval of Non-Preferred XaJanz products. [documentation required]

Continuation approval for Xeljanz in Psoriatic Arthritis or Juvenile Idiopathic Arthritis: Requires verification of prior use (claims history or prescriber verification) and documentation of clinical benefit or lack of alternatives per agent-specific continuation criteria. Approval length typically 1 year.

Offer alternate products when Xeljanz criteria partially met: If a patient meets some but not all Xeljanz criteria and Preferred alternatives remain appropriate, prescribers should be offered or required to try Preferred agents first; exceptions allowed with documentation of contraindication/intolerance or prior failure. [documentation required]

Other Conditions — Xeljanz oral solution: Follow the product-specific PA criteria and program-wide verification/documentation rules for initiation and continuation. [documentation required where noted]

Actemra subcutaneous (tocilizumab SC) — Psoriatic Arthritis: When requested for PsA, Actemra SC requires meeting the product-specific PA criteria and any directed Step therapy trials; if the directed trial is not completed, prescriber documentation of contraindication/intolerance or prior failure is required for approval. [documentation required]

Approvals for other agents referenced: For any agent referenced in a directed trial or substitution pathway, approvals are subject to that agent’s PA criteria and the program-wide rules on verification, documentation, and approval duration. [documentation required]

Formulary status entries / indication mappings: Approvals and directed trial requirements follow the formulary Step 1/Step 2 mapping for rheumatology indications as documented in the Preferred and Non-Preferred Products table; consult the table for which agents are Step 1 Preferred for each indication. Any exceptions or directed non-preferred pathways described in the table must be followed and documented accordingly.

Bimzelx directed to one Step 1 product for some indications.

Step 3a Non-Preferred (directed to TWO Step 1 or 2a Products): Examples include: Cimzia, Kevzara, Kineret, Olumiant, Orencia SC, Simponi SC, Cosentyx SC, Ilumya, Siliq depending on indication — documentation required.2 products

A trial of multiple products of the same biologic counts as ONE product.

Step 3b Non-Preferred (directed to ONE Step 1 Product AND Tyenne SC): Actemra SC (tocilizumab) examples where directed to one Step 1 plus Tyenne SC — documentation required.

Recent formulary mapping changes call out several NDC‑level edits: NDCs for Humira (adalimumab) with prefixes 00074* and Hyrimoz NDCs starting with 61314* were removed from Preferred lists across many indications, although prior trials using those NDCs still count toward an adalimumab trial. Conversely, adalimumab‑ryvk (Simlandi) NDCs beginning with 82009* are specified as a Preferred adalimumab product. Other material updates include addition of Tremfya SC and Omvoh SC to Preferred mappings for Crohn's disease and Ulcerative Colitis, and additions/extensions of agents such as Cimzia into new Step assignments for selected indications. These changes reflect recent effective‑date revisions and should be used to orient reviewers to recent formulary mapping shifts.

Ankylosing Spondylitis - Initial Therapy: Approve for 6 months if BOTH met: standard Cimzia PA AND tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, or Xeljanz/XR.2 prior products

Documentation required.

Juvenile Idiopathic Arthritis - Initial Therapy: Approve for 6 months if BOTH met: standard Cimzia PA AND tried TWO of a tocilizumab SC product, Enbrel, an adalimumab product, Rinvoq/Rinvoq LQ, and Xeljanz.2 prior products

Trials of tocilizumab IV, Kevzara, Orencia IV/SC, infliximab products, or Simponi Aria also count.

Psoriatic Arthritis - Initial Therapy: Approve for 6 months if BOTH met: standard Cimzia PA AND tried TWO of Enbrel, an adalimumab product, Otezla/Otezla XR, Skyrizi SC, ustekinumab SC product, Taltz, Tremfya SC, Rinvoq/Rinvoq LQ, or Xeljanz/XR.2 prior products

Documentation required.

Plaque Psoriasis - Initial Therapy: Approve for 3 months if BOTH met: standard Cimzia PA AND tried TWO of Enbrel, an adalimumab product, Otezla/Otezla XR, Skyrizi SC, Sotyktu, ustekinumab SC product, Taltz, or Tremfya SC.2 prior products

Documentation required.

Crohn's Disease - Initial Therapy: Approve for 6 months if BOTH met: standard Cimzia PA AND tried ONE of an adalimumab product, Omvoh SC, Skyrizi SC (on-body), ustekinumab SC product, Tremfya SC, or Zymfentra.1 prior product

Patient currently receiving Cimzia: Approve for 1 year if BOTH met: standard Cimzia PA AND ONE of criteria a–g (examples include prior trials per indication OR established on Cimzia ≥90 days with claims verification of at least a 90-day supply within past 130 days or prescriber verification if claims unavailable).>=90 days within 130-day look-back

Verification in prescription claims history required or prescriber verification when claims unavailable; paid-claims only (no samples/coupons).

Other Conditions: Approve Cimzia (initial therapy for duration as directed or 1 year for continuing) if patient meets standard Cimzia PA Policy criteria.

Product-specific general approval statement examples

Examples of product-level approvals when standard product-specific PA criteria are met.

Enbrel general: Enbrel: Approve (initial therapy as directed or 1 year for patient continuing therapy) if patient meets standard Enbrel PA Policy criteria.
Adalimumab products general: Adalimumab-adaz, adalimumab-adbm, Simlandi, adalimumab-ryvk (NDCs starting with 82009): Approve (initial therapy as directed or 1 year for continuing) if patient meets standard Adalimumab Products PA Policy criteria.
Multiple adalimumab products count as ONE trial where noted.
Simponi SC general: Simponi Subcutaneous: Approve for indications if patient meets standard Simponi Subcutaneous PA Policy criteria and required prior trials per condition.
For current users, continuation verification rules (>=90-day supply in past 130 days or prescriber verification) apply.

Continuation-specific rules and claims verification logic

Remaining branches that contain continuation-specific rules and indication-specific 'current user' verification logic. Include required claims verification thresholds as noted.

Continuation-specific and current-user verification rules

General continuation verification: For continuation approvals across non-preferred and preferred agents: prescription claims history must indicate at least a 90-day supply dispensed within the past 130 days OR prescriber verification if claims unavailable; exceptions allowed only if prescriber verifies paid claims (no samples/coupons).>=90 days within 130-day look-back
Applies to Simponi, Cosentyx, Bimzelx, Orencia, Olumiant, Rinvoq, Xeljanz, Entyvio, etc.
Xeljanz continuation - PsA or JIA specific: Approve for 1 year if patient meets standard Xeljanz PA criteria AND ONE of: for JIA/PsA patient has tried specified prior agents (one of Enbrel or adalimumab examples) OR patient has been established on Xeljanz for ≥90 days with claims indicating ≥90-day supply within past 130 days (or prescriber verification if claims unavailable).>=90/130 or prior trial
If 130-day claims history unavailable, prescriber verification that patient received Xeljanz ≥90 days and via paid claims allowed.
Simponi / Cosentyx / Bimzelx current-user continuations: Current user continuation logic: patient established on agent for ≥90 days and prescription claims history indicates ≥90-day supply dispensed within past 130 days OR prescriber verification if claims unavailable; approval durations typically 1 year for continuation.>=90/130
Documentation required; paid-claims only.
Claims verification note as threshold on relevant leaf nodes: Where continuation criteria reference verification, treat the >=90-day supply within 130-day look-back as the numeric threshold for claims verification on continuation leaf criteria.>=90/130

List preferred products tried (agent name, dose, start/stop dates)
Provide clinical rationale if trial not completed or insufficient
Attach chart notes or claims history substantiating trials

Documentation Required

Verification for continuation of non-preferred therapy

For continuation of a non-preferred therapy, verify treatment history via prescription claims whenever available. If 130 days of prescription claims history are available, claims must show the patient received the non-preferred product for the required continuous period (typically 90 or 120 days) within a 130-day look-back. When claims history is not available, the prescriber must provide attestation and documentation that the patient received the non-preferred product (no samples/coupons) for the specified period.

If >=130 days of claims history exist, submit claims showing 90 or 120 days of therapy within a 130-day look-back
If <130 days of claims history, prescriber verification is required confirming paid claims (no samples/coupons)
Include dates, dosing, and dispensing records in verification

Documentation Required

Claims history verification

Claims history verification is required for continuation approvals. Reviewers will check prescription claims records to confirm duration of therapy; when claims cannot confirm, prescriber attestation and supporting documentation are required. This applies to all oral and subcutaneous non-preferred products referenced in the policy.

Confirm paid-claim dispensing for the required duration (90 or 120 days as specified)
Document absence of sample/coupon use if prescriber attests to prior use
Attach pharmacy dispensing history or insurance claim lines

Billing Rule

Approval duration and units

Approvals for continuation of therapy (Preferred or Non-Preferred products) are normally authorized for 1 year (12 months) unless otherwise noted. When initial approval intervals are provided in months, use 30 days = 1 month. Include units and duration on the approval notice per payer billing requirements.

Standard approval duration: 1 year (12 months) for continuation
If monthly authorization issued, 1 month = 30 days
Ensure units and days supplied match approved duration on claims

Step Therapy

Step requirements / Offer Alternatives

When prior-trial criteria are not met, providers must offer and document alternatives directed to the required Step 1 preferred product(s). Denials may occur if alternatives are available and not tried; when medically necessary reasons preclude a preferred agent, document the clinical justification.

If Step criteria unmet, recommend and document trial of the specified Step 1 preferred product(s)
If a preferred product is contraindicated or not tolerated, provide clinical justification and supporting documentation
Document any patient refusal or access barriers to preferred products

2025-03-12formulary_update

Material: Tremfya subcutaneous (SC) added as a Preferred Product for Crohn's Disease; Entyvio, Cimzia, and Rinvoq criteria updated to include Tremfya SC as Preferred.

2025-04-18formulary_update

Material: Tremfya SC added as a Preferred Product for Crohn's Disease (effective 04/18/2025) and criteria updated across related agents.

2025-06-04formulary_update

Material: Multiple ustekinumab SC products (Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC, Imuldosa SC) added as Preferred ustekinumab subcutaneous products; criteria across many Non-Preferred products updated to reference these Preferred ustekinumab SC products.

2025-08-06formulary_update

Material: Omvoh subcutaneous added as a Preferred Product for Crohn's Disease; Cimzia, Rinvoq, and Entyvio SC criteria updated to include Omvoh SC (previous trial of Omvoh IV may also count).

2025-10-01formulary_update

Material: Imuldosa SC added as a Preferred ustekinumab SC product; multiple Non-Preferred product criteria updated to include Imuldosa SC as Preferred.

2025-10-29formulary_update

Material: Policy revisions note removal of Cyltezo as a Preferred adalimumab product and specification that adalimumab-ryvk NDCs starting with 82009 are the Preferred adalimumab product; adalimumab-aacf added as an example. (Selected revision reflected prior-year changes.)

2025-11-19formulary_update

Material: Additional selected revisions through late 2025 clarified step mappings and preferred lists across indications (including Tremfya SC clarifications and Omvoh mappings).

2026-01-01formulary_updateLatest

Material: Review date 09/10/2025 with selected revisions effective 01/01/2026; consolidated policy effective 01/01/2026 reflects prior changes including removal of Humira (00074*) and Hyrimoz (61314*) from Preferred lists (prior trials still count), designation of adalimumab-ryvk NDCs starting with 82009 as Preferred, additions of Tremfya SC and Omvoh SC into Preferred mappings for Crohn's disease and Ulcerative Colitis, additions of several ustekinumab SC products (Imuldosa, Selarsdi, ustekinumab-ttwe, Yesintek) as Preferred, Cimzia step/assignment expansions (including counts toward Preferred trials and inclusion in some Step assignments), and other Preferred additions (e.g., Velsipity for UC).