CurrentCignaPolicy N/A

Cimzia Prior Authorization Form

Prior authorization request form for Cimzia (certolizumab pegol) to collect patient, prescriber, clinical, and utilization information required for Cigna's coverage review and decision-making. The form captures indication, prior therapies, objective response assessments, setting of administration, dispensing vendor, and attestation/documentation requirements.

Policy Summary

PayerCigna

PolicyCimzia Prior Authorization Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionComplete all asterisked patient and prescriber fields and attach chart notes or claims to support prior therapy trials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted; this is an administrative prior authorization form used to collect information for review.

9Listed Indications (checkbox options)

3Cimzia NDC presentations listed

1Preferred specialty pharmacy (Accredo) noted

Policy summary

This is a Cigna prior authorization form for Cimzia (certolizumab pegol) used to collect clinical and administrative information required to evaluate medical necessity across multiple labeled indications. The form documents the medication requested including specific Cimzia presentations and NDCs, the indication/diagnosis selected from the listed options, prior biologic and conventional/systemic therapy trials, and objective response assessments tied to duration of prior Cimzia exposure.

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Captured elements include: indication (checkbox list including AS, CD, JIA, nr-axSpA, CPP, PsA, RA, other spondyloarthritis, other), prior therapies (multiple biologic and systemic therapy checklists with requirements to attach medical documentation), objective response assessments (standardized disease activity scores, lab markers, imaging, endoscopy, or symptom improvement questions for patients on Cimzia ≥6 months), prescriber specialty and consultation requirements (rheumatology, gastroenterology, dermatology depending on indication), and administration/dispensing logistics (where drug will be obtained, administration setting, facility/dispensing details including Accredo as preferred specialty pharmacy).

Information captured to determine medical necessity

General Authorization Criteria Capture

Form collects information to determine medical necessity and documents trials, prescriber specialty, and response assessments. These are not explicit decision rules on the form but map to Cigna's coverage review requirements.

All asterisked items must be completed or Cigna will not respond via fax

Patient and prescriber identifiers completed for privacy-compliant response

Include Cigna ID, DOB, DEA/NPI/TIN, and required contact information per form

Medication requested specified (Cimzia formulations and NDCs provided)

Cimzia 200 mg single-dose vial (NDC 50474 0700 62); Cimzia 200mg prefilled kit (NDC 50474 0710 79); Cimzia 400mg/2ml syringe kit (NDC 50474 0710 81)

Indication selected from list (AS, CD, JIA, nr-axSpA, CPP, PsA, RA, other spondyloarthritis, other)

Diagnosis ICD-10 to be provided on form

Prescriber specialty/consultation: Prescriber specialty and whether prescribed by or in consultation with specialist (rheumatologist, gastroenterologist, dermatologist) documented when required by indication

Form asks specialty and specific consultation requirements per indication

Prior therapy documentation requirements

General prior therapies (all patients): Has the patient tried specified biologics or other agents per indication (forms list multiple agent checkboxes)
Examples and lists provided per diagnosis; documentation must be attached
Verification for ongoing Cimzia ≥90 days: If did not try required comparators, prescriber may verify patient has been receiving Cimzia ≥90 days
If verifying ongoing therapy, prescriber must verify paid claims (not samples/coupons)
New start/concomitant therapy requirements: For new starts, many indications require trial of corticosteroids or conventional systemic therapy or at least one systemic agent unless contraindicated
Examples and exceptions provided per diagnosis (eg, Crohn's, psoriasis, JIA)

Prior Cimzia exposure and objective response: For patients with prior Cimzia exposure (specified durations like ≥6 months or ≥3 months depending on indication), form requires documentation of beneficial clinical response assessed by objective measures appropriate to indication

Lists of objective measures provided per diagnosis (disease activity scores, labs, imaging, endoscopy, reduced corticosteroid dose)

Crohn's disease specific requirements: For Crohn's disease, additional surgical/fistula criteria and gastroenterology prescribing/consult required when relevant

Questions on corticosteroid trial, other systemic agent trial, prior biologic trial, presence of fistulas, ileocolonic resection, and gastroenterologist involvement

Administration and dispensing: Administration setting and dispensing source indicated; form lists Accredo specialty pharmacy and other options, and asks where drug will be administered

Cigna notes Accredo as nationally preferred specialty pharmacy and that infusion should occur in least intensive appropriate setting per some plans

What providers must do

Documentation Required

Complete all required patient/prescriber fields

All asterisked (*) items on the form must be completed for Cigna to respond via fax. Include patient and prescriber identifiers and required contact information. Ensure the following required identifiers and contact fields are provided so the request can be processed and Cigna can communicate the outcome.

Cigna ID
Date of Birth (DOB)
DEA, NPI, or TIN
Office contact name, phone, and fax

Documentation Required

Attach medical documentation of prior therapy trials

Attach medical documentation that supports the prior therapy checklist entries. Accepted documentation includes chart notes, prescription claims records, or receipts and must include patient-specific identifying information. Failure to attach the requested documentation may result in denial of the request.

Chart notes with patient identifiers
Prescription claims records
Prescription receipts

Prior Authorization

Submit prior authorization via form or online

Submit the prior authorization using this form or electronically via CoverMyMeds or SureScripts in your EHR. Standard response time for prescription drug coverage requests is 5 business days. If the request is urgent, call Cigna to request expediting the review.

Billing Rule

Indicate dispensing/administration location and billing intent

Indicate where the medication will be obtained and how it will be billed. The form asks the provider to specify the dispensing/administration source (for example, Accredo specialty pharmacy, hospital outpatient, retail pharmacy, home infusion, or physician office stock) and whether billing will be on a medical claim when office/physician stock is used.

Documentation Required

Verify paid claims for ongoing Cimzia therapy when required

If the prescriber indicates the patient has been receiving Cimzia for at least 90 days, the form requires verification that therapy was received via paid claims (not samples, coupons, or other waivers). This verification must be provided when asked on the form.

Background and definitions

Purpose: This form is designed to capture the clinical and administrative information Cigna requires to review and determine coverage/medical necessity for Cimzia across its multiple labeled indications. It collects diagnosis selection, prior therapy trials (with required supporting documentation), objective measures of response when applicable, and details about prescriber specialty and whether consultation with a specialist has occurred.

Specialties involved include rheumatology, gastroenterology, and dermatology (the form asks whether the medication is being prescribed by or in consultation with a rheumatologist, gastroenterologist, or dermatologist depending on the indication). The form maps to Cigna's coverage review requirements by listing indication-specific prior therapy and objective-response documentation needs but is not itself an explicit decision rule; completion and attached documentation support Cigna's adjudication process and failure to provide required items may prevent a response or result in denial.

Definitions

Objective measuresStandardized disease activity scores, lab markers (CRP, ESR), imaging, endoscopy, or reduction in corticosteroid dose as specified per indication on the form.

50474-0700-62	Cimzia 200 mg single-dose vial (listed as NDC 50474 0700 62 on form)
50474-0710-79	Cimzia 200 mg prefilled kit (listed as NDC 50474 0710 79 on form)
50474-0710-81	Cimzia 400 mg/2 ml syringe kit (listed as NDC 50474 0710 81 on form)

OpenPayer

Cimzia Prior Authorization Form

Policy summary

Information captured to determine medical necessity

Product codes listed on form

What providers must do

Background and definitions

Document changes