CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cimzia (certolizumab pegol) (Subcutaneous

Coverage and utilization management policy for certolizumab pegol (Cimzia) for Medicaid, Commercial, and Medicare-Medicaid Plan (MMP) members; includes authorization length, quantity limits, dosing, indication-specific initial and renewal criteria, safety screening requirements, billing codes and covered diagnosis codes (appendix).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCimzia (certolizumab pegol) (Subcutaneous

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2020

Next Review Date

Key ActionInitial and renewal coverage determined by meeting the universal and indication-specific criteria; authorization length is 6 months and may be renewed based on response and toxicity monitoring.

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this update.

6 monthsAuthorization length

J0717Primary HCPCS code

50474-0700-xx, 50474-0710-xxNDCs listed

MultipleCovered indications

~140Listed ICD-10 codes (approx)