UnitedHealthcare Cimzia Coverage Update: Prior Auth

Coverage and Medical Necessity Criteria

Initial and continuation coverage criteria — Crohn's Disease

Crohn's Disease (CD) — Covered when ALL of the following are met

For initial therapy: Diagnosis of moderately to severely active Crohn's disease; and one of: history of inadequate response to conventional therapies (examples include anti-inflammatory drugs, corticosteroids, or oral immunosuppressive agents) OR prior treatment with a systemic targeted immunomodulator FDA‑approved for Crohn's disease (examples listed in policy) OR patient is currently on Cimzia; and prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia FDA labeled for self-administration (prescriber must submit explanation) when that pathway is used; and Cimzia is initiated and titrated according to US FDA labeled dosing for CD; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and initial authorization will be issued for 12 months.

Prescriber attestation required if patient/caregiver cannot self-administer.

For continuation of therapy: Documentation of positive clinical response; and prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia FDA labeled for self-administration (prescriber must submit explanation) when that pathway is used; and Cimzia is initiated and titrated according to US FDA labeled dosing for CD; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and authorization will be issued for 12 months.

Continuation requires documentation of positive clinical response.

Initial and continuation coverage criteria — Rheumatoid Arthritis

Rheumatoid Arthritis (RA) — Covered when ALL of the following are met

For initial therapy: Diagnosis of moderately to severely active rheumatoid arthritis; and one of: history of failure or intolerance to a 3-month trial of one non-biologic DMARD at maximally indicated doses unless contraindicated OR prior treatment with a systemic targeted immunomodulator FDA‑approved for RA OR patient is currently on Cimzia; and prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia FDA labeled for self-administration (prescriber must submit explanation) when that pathway is used; and Cimzia is initiated and titrated according to US FDA labeled dosing for RA; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and initial authorization will be issued for 12 months.

Prescriber attestation required if patient/caregiver cannot self-administer; prescribed by or in consultation with a rheumatologist when attestation pathway used.

For continuation of therapy: Documentation of positive clinical response; and prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia FDA labeled for self-administration (prescriber must submit explanation) when that pathway is used; and Cimzia is initiated and titrated according to US FDA labeled dosing for RA; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and authorization will be issued for 12 months.

Initial and continuation coverage criteria — Psoriatic Arthritis

Psoriatic Arthritis (PsA) — Covered when ALL of the following are met

For initial therapy: Diagnosis of active psoriatic arthritis; and one of: history of failure to a 3-month trial of methotrexate at maximally indicated dose unless contraindicated OR prior treatment with a systemic targeted immunomodulator FDA‑approved for PsA OR patient is currently on Cimzia; and prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia FDA labeled for self-administration (prescriber must submit explanation) when that pathway is used; and Cimzia is initiated and titrated according to US FDA labeled dosing for PsA; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and initial authorization will be issued for 12 months; and prescribed by or in consultation with a rheumatologist or dermatologist when attestation pathway used.

Prescriber attestation required if patient/caregiver cannot self-administer.

For continuation of therapy: Documentation of positive clinical response; and prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia FDA labeled for self-administration (prescriber must submit explanation) when that pathway is used; and Cimzia is initiated and titrated according to US FDA labeled dosing for PsA; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and authorization will be issued for 12 months.

Continuation requires documentation of positive clinical response.

Initial and continuation coverage criteria — AS and nr-axSpA

Ankylosing Spondylitis (AS) and Non-Radiographic Axial Spondyloarthritis (nr-axSpA) — Covered when ALL of the following are met

For initial therapy: Diagnosis of active ankylosing spondylitis or non-radiographic axial spondyloarthritis; and one of: history of failure to two NSAIDs each used for at least 4 weeks at maximally indicated doses unless contraindicated OR prior treatment with a systemic targeted immunomodulator FDA‑approved for AS/nr-axSpA OR patient is currently on Cimzia; and prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia FDA labeled for self-administration (prescriber must submit explanation) when that pathway is used; and Cimzia is initiated and titrated according to US FDA labeled dosing for AS or nr-axSpA; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and initial authorization will be issued for 12 months; and prescribed by or in consultation with a rheumatologist when attestation pathway used.

Prescriber attestation required if patient/caregiver cannot self-administer.

For continuation of therapy: Documentation of positive clinical response; and prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia FDA labeled for self-administration (prescriber must submit explanation) when that pathway is used; and Cimzia is initiated and titrated according to US FDA labeled dosing for AS or nr-axSpA; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and authorization will be issued for 12 months.

Initial and continuation coverage criteria — Plaque Psoriasis

Plaque Psoriasis (PS) — Covered when ALL of the following are met

For initial therapy: Diagnosis of moderate to severe plaque psoriasis; and one of: greater than or equal to 3% body surface area involvement or palmoplantar, facial, genital, or severe scalp involvement plus history of failure to one listed topical therapy unless contraindicated and history of failure to a 3-month trial of methotrexate at maximally indicated dose unless contraindicated OR prior treatment with a systemic targeted immunomodulator FDA‑approved for plaque psoriasis OR patient is currently on Cimzia; and Cimzia is initiated and titrated according to US FDA labeled dosing for PS; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and initial authorization will be issued for 12 months; and prescribed by or in consultation with a dermatologist when attestation pathway used.>=3% BSA or specific site involvement

Topical therapies listed in policy; methotrexate trial requirement applies on this path.

For continuation of therapy: Documentation of positive clinical response; and Cimzia is initiated and titrated according to US FDA labeled dosing for PS; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and authorization will be issued for 12 months.

Continuation requires documentation of positive clinical response.

Initial Therapy

Covered when ALL of the following are met for initial therapy:

Initial Therapy - general: Diagnosis of the specified condition; Cimzia initiated and titrated according to US FDA labeled dosing for the indication; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication; and initial authorization for 12 months (unless indication-specific limits apply).

Prescriber attestation pathway may apply for self-administration exceptions per indication.

Continuation Therapy

For continuation of therapy, ALL must be met:

Continuation Therapy - general: Documentation of positive clinical response; Cimzia is initiated and titrated according to US FDA labeled dosing for the indication; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication; prescriber attestation regarding inability to self-administer when applicable; authorization typically issued for 12 months.

Specific specialty prescriber requirements apply for some indications (e.g., gastroenterologist for Crohn's, rheumatologist for RA/AS, dermatologist for PS).

Medical Necessity - Plaque Psoriasis (alternative paths)

Medically necessary for initial therapy when ALL of the following are met (one of the following sub-paths):

Severity + topical + methotrexate failure path: All of the following: >=3% BSA or palmoplantar/facial/genital/severe scalp involvement; history of failure to one listed topical therapy unless contraindicated; and history of failure to a 3-month trial of methotrexate at maximally indicated dose unless contraindicated.>=3% BSA

Topical therapies listed include corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar.

Prior systemic targeted immunomodulator path: Patient has been previously treated with an FDA-approved systemic targeted immunomodulator for plaque psoriasis (examples listed in policy).

Examples provided in policy.

Currently on Cimzia: Patient is currently on Cimzia.

Initial Therapy - PJIA

Covered when ALL of the following are met for initial therapy:

PJIA initial: Diagnosis of active polyarticular juvenile idiopathic arthritis (PJIA); Cimzia is initiated and titrated according to US FDA labeled dosing for PJIA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and initial authorization is for no more than 12 months.

Continuation Therapy - PJIA

For continuation of therapy, ALL must be met:

PJIA continuation: Patient has previously received Cimzia injection for intravenous infusion; and documentation of positive clinical response; and Cimzia is dosed according to US FDA labeled dosing for PJIA; and patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); and authorization is for no more than 12 months.

Prescriber attestation pathway also described requiring explanation and rheumatologist involvement when used.

Revised coverage criteria (02/01/2026)

Coverage criteria revisions (summary):

General revisions: Replaced references to 'targeted immunomodulator' with 'systemic targeted immunomodulator'; added a medical necessity criterion requiring prescriber attestation that the patient or caregiver is not able to be trained or are physically unable to administer Cimzia U.S. FDA labeled for self-administration (prescriber must submit explanation); and updated lists of systemic targeted immunomodulators across indications (agents added, removed, or renamed).

From policy revision 02/01/2026.

Indication-specific medication list changes

Indication-specific updates to lists of systemic targeted immunomodulators that affect combination therapy/previous-treatment requirements:

Crohn's Disease updates: Examples: Added Entyvio (vedolizumab), Omvoh (mirikizumab-mrkz), Tremfya (guselkumab); removed Enbrel (etanercept), Olumiant (baricitinib), Orencia (abatacept), Simponi (golimumab), Xeljanz (tofacitinib); standardized naming for ustekinumab.

See policy revision summary.

Rheumatoid Arthritis updates: Replaced 'Xeljanz (tofacitinib)' with 'Xeljanz/Xeljanz XR (tofacitinib)' in examples of systemic targeted immunomodulators; other list updates noted.

See policy revision summary.

Psoriatic Arthritis and Plaque Psoriasis updates: Added agents such as Bimzelx (bimekizumab-bkzx) and others; removed select agents (examples provided); standardized naming for several agents (e.g., ustekinumab, Xeljanz/XR).

See policy revision summary chunks.

Use of Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication is not allowed. The policy explicitly requires that for both initial and continuation therapy across labeled indications (including Crohn's disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis/nr-axSpA, plaque psoriasis, and polyarticular juvenile idiopathic arthritis) the patient must not be receiving Cimzia concurrently with another systemic targeted immunomodulator for the same condition; initial and continuation authorizations are typically issued for 12 months when other coverage criteria are met.

This policy restates that Cimzia must not be used in combination with another systemic targeted immunomodulator for the treatment of the same indication. The exclusion is reiterated within each indication-specific section (e.g., plaque psoriasis, Crohn’s disease, psoriatic arthritis, rheumatoid arthritis, AS/nr-axSpA, and pJIA) and applies to both initial and continuation therapy determinations.

Coverage decisions are determined by the member′s specific benefit plan and applicable state or federal mandates; where such mandates apply they supersede this policy. The policy notes that some Certificates of Coverage may allow experimental, investigational, or off‑label uses under defined conditions, and that FDA approval alone is not a basis for coverage — FDA indications are provided for information only.

Requests for concurrent use of Cimzia with another systemic targeted immunomodulator for the same indication are not supported by the clinical criteria in this policy. Each indication section requires that the patient not be receiving Cimzia in combination with listed systemic targeted immunomodulators (examples provided in the indication lists), and continuation criteria likewise require absence of concomitant systemic targeted immunomodulator therapy.

Operationally, any prior authorization request documenting concurrent Cimzia plus another systemic targeted immunomodulator for the same indication may be denied as not meeting medical necessity per this policy. The policy language specifically identifies that for both initial and continuation approvals the patient must not be receiving Cimzia in combination with the agents listed for each indication.

FDA approval and the FDA‑labeled indications for Cimzia are presented for informational purposes; the policy states that FDA approval alone is not a basis for coverage and that FDA labeling should not be the sole determinant of coverage decisions.

Initial Therapy Requirements by Indication

Initial therapy — shared/common elements across indications

Initial therapy requirements vary by indication but share common elements

Initial therapy — shared elements: Diagnosis of the specified active condition; one of: prior trial/failure of indicated conventional therapies at maximally indicated doses and durations unless contraindicated OR prior treatment with an FDA‑approved systemic targeted immunomodulator for the condition OR patient is currently on Cimzia; Cimzia initiated and titrated according to US FDA labeled dosing for the indication; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication (examples listed in policy); prescriber attestation that patient/caregiver cannot be trained or are physically unable to self-administer when that pathway is used (prescriber must submit explanation); indication-specific prescriber specialties apply when attestation pathway is used; initial authorization typically issued for 12 months.

See individual indication criteria for exact prior-therapy requirements (e.g., methotrexate trial for PsA and PS, two NSAIDs for AS/nr-axSpA).

Initial therapy — indication-specific rules, dosing per FDA labeling, and concomitant therapy restrictions

Initial therapy coverage rules differ by indication and include diagnosis, dosing per FDA labeling, and restrictions on concomitant targeted immunomodulators. For plaque psoriasis additional step requirements apply (topical failure and methotrexate trial) unless prior systemic targeted therapy or current Cimzia use.

Continuation Therapy Requirements

Continuation therapy — common conditions across indications for continued coverage

Continuation therapy conditions common across indications

Continuation — common conditions: Documentation of positive clinical response; Cimzia initiated and titrated according to US FDA labeled dosing for the indication; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples listed in policy); prescriber attestation regarding inability to self-administer when applicable; authorization typically issued for 12 months.

Specific specialty prescriber requirements apply for some indications.

Continuation therapy — requires documentation of positive clinical response and dosing per FDA labeling; exclusion of combination therapy

Continuation therapy requires documentation of positive clinical response and dosing per FDA labeling; no combination with other systemic targeted immunomodulators; authorizations issued for up to 12 months.

Continuation — documentation and exclusions: Documentation of positive clinical response is required; Cimzia must be dosed per US FDA labeling for the indication; patient must not be receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication; authorization durations follow indication-specific limits (commonly 12 months or no more than 12 months for PJIA).

Prior Treatment and Step Therapy Requirements

Indication	Prior trials / required prior treatment for initial coverage
Crohn's disease (moderately to severely active)	One of the following: history of inadequate response to conventional therapies (e.g., corticosteroids, oral immunosuppressive agents) at maximally indicated doses unless contraindicated; OR prior treatment with an FDA‑approved systemic targeted immunomodulator for Crohn's disease; OR currently receiving Cimzia.
Rheumatoid arthritis (moderately to severely active)	One of the following: failure/intolerance to a 3‑month trial of one non‑biologic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine) at maximally indicated doses unless contraindicated; OR prior treatment with an FDA‑approved systemic targeted immunomodulator for RA (examples listed in policy); OR currently on Cimzia.
Psoriatic arthritis (active)	One of the following: failure to a 3‑month trial of methotrexate at maximally indicated dose unless contraindicated; OR prior treatment with an FDA‑approved systemic targeted immunomodulator for PsA (examples listed in policy); OR currently on Cimzia.
Ankylosing spondylitis / non‑radiographic axial spondyloarthritis (active)	One of the following: failure to two NSAIDs (each used ≥4 weeks at maximally indicated doses) unless contraindicated; OR prior treatment with an FDA‑approved systemic targeted immunomodulator for AS/nr‑axSpA; OR currently on Cimzia.
Plaque psoriasis (moderate to severe)	One of the following: (A) ≥3% BSA involvement or palmoplantar/facial/genital/severe scalp involvement plus history of failure to one topical therapy and failure of a 3‑month trial of methotrexate at maximally indicated dose unless contraindicated; OR (B) prior treatment with an FDA‑approved systemic targeted immunomodulator for plaque psoriasis; OR (C) currently on Cimzia.
Polyarticular juvenile idiopathic arthritis (active PJIA)	Diagnosis of active PJIA and Cimzia initiated per FDA dosing; patient must not be receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication; prior treatment paths include prior systemic targeted immunomodulator or current Cimzia as applicable per policy.

Plaque psoriasis step requirement	Details / alternative paths
Topical therapy failure + methotrexate trial	Patient must have ≥3% BSA involvement or involvement of palmoplantar, facial, genital, or severe scalp psoriasis; history of failure to one listed topical therapy (e.g., corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar) unless contraindicated; AND history of failure to a 3‑month trial of methotrexate at maximally indicated dose unless contraindicated.
Prior systemic targeted immunomodulator	Alternative path: prior treatment with an FDA‑approved systemic targeted immunomodulator for plaque psoriasis (examples listed in policy) satisfies the step requirement instead of topical/methotrexate failures.
Currently on Cimzia	Alternative path: patient currently receiving Cimzia meets initial therapy requirement without additional topical/methotrexate trials.

Change type	Details of step‑therapy / prior‑therapy list updates
Added and removed agents in prior/concomitant lists	Policy updates modify which systemic targeted immunomodulators count as prior or concurrent therapies. Examples: added Bimzelx (bimekizumab‑bkzx), Cosentyx (secukinumab), Taltz (ixekizumab), Sotyktu (deucravacitinib), Bimzelx and others across indications; removed agents such as Olumiant (baricitinib) in some lists (see policy summary).
Standardized naming / replacements	Replacements and standardizations include replacing 'Stelara (ustekinumab)' with 'ustekinumab' and 'Xeljanz (tofacitinib)' with 'Xeljanz/ Xeljanz XR (tofacitinib)'.
Indication‑specific updates	Examples by indication: Psoriasis lists: added Bimzelx, Cosentyx, Enbrel, Ilumya, Siliq, Sotyktu, Taltz and removed Olumiant, Orencia, Rinvoq, Simponi, Xeljanz in the 'must not be receiving' or 'previously treated' examples; AS/nr‑axSpA lists: added Bimzelx, Cosentyx, Taltz and updated prior‑therapy examples. (See policy change summary for full lists.)

Applicable Coding

Applicable HCPCSHCPCS

J0717

Injection, certolizumab pegol, 1 mg (code may be used when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

Applicable ICD-10 Codes (partial list)ICD-10

K31.6	Fistula of stomach and duodenum.
K50.00	Crohn's disease of small intestine without complications.
K50.011	Crohn's disease of small intestine with rectal bleeding.
K50.012	Crohn's disease of small intestine with intestinal obstruction.
K50.013	Crohn's disease of small intestine with fistula.
K50.014	Crohn's disease of small intestine with abscess.
K50.018	Crohn's disease of small intestine with other complication.
K50.019	Crohn's disease of small intestine with unspecified complications.
K50.10	Crohn's disease of large intestine without complications.
K50.111	Crohn's disease of large intestine with rectal bleeding.

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Applicable ICD-10 Diagnosis CodesICD-10

M05.439	Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist
M05.441	Rheumatoid myopathy with rheumatoid arthritis of right hand
M05.442	Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.449	Rheumatoid myopathy with rheumatoid arthritis of unspecified hand
M05.451	Rheumatoid myopathy with rheumatoid arthritis of right hip
M05.452	Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.459	Rheumatoid myopathy with rheumatoid arthritis of unspecified hip
M05.461	Rheumatoid myopathy with rheumatoid arthritis of right knee
M05.462	Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.469	Rheumatoid myopathy with rheumatoid arthritis of unspecified knee

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Applicable ICD-10 CodesICD-10

M08.851	Other juvenile arthritis, right hip.
M08.852	Other juvenile arthritis, left hip.
M08.859	Other juvenile arthritis, unspecified hip.
M08.861	Other juvenile arthritis, right knee.
M08.862	Other juvenile arthritis, left knee.
M08.869	Other juvenile arthritis, unspecified knee.
M08.871	Other juvenile arthritis, right ankle and foot.
M08.872	Other juvenile arthritis, left ankle and foot.
M08.879	Other juvenile arthritis, unspecified ankle and foot.
M08.88	Other juvenile arthritis, vertebrae.

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Plaque psoriasis severity threshold — BSA or specific site involvement

Severity threshold>= 3% body surface area (BSA) involvement

Alternative site involvementInvolvement of palmoplantar areas

Alternative site involvementFacial involvement

Alternative site involvementGenital involvement

Alternative site involvementSevere scalp psoriasis

Removed CPT codes

Prior Authorization, Documentation, and Prescriber Actions

Prior Authorization

Prior Authorization Requirements and Authorization Duration

Prior authorization is required for Cimzia. Initial authorizations are generally issued for up to 12 months when criteria are met. Continuation/renewal authorizations are issued for up to 12 months when documentation demonstrates a positive clinical response. Requests that lack required documentation (including the diagnosis, prior therapy trials, or prescriber attestation when applicable) may be denied or returned for additional information.

Initial authorization: up to 12 months when all initial criteria are met
Continuation authorization: up to 12 months with documentation of positive clinical response
Requests missing required documentation (diagnosis, prior therapy, attestation) risk denial

Documentation Required

Prescriber Self-Administration Attestation

Prescriber attestation is required when the patient or caregiver cannot be trained or are physically unable to self-administer Cimzia (U.S. FDA labeled for self-administration). The prescriber must submit an explanation supporting the attestation. Failure to provide the required attestation and explanation may affect approval of the request.

Pharmacy vs Medical Benefit

Billing Rule

Site‑of‑care billing: pharmacy for self‑administered, medical for provider‑administered

Self‑administered Cimzia is typically dispensed under the pharmacy benefit; provider‑administered formulations (or medical‑benefit administration) are billed under the medical benefit unless the member's benefit plan specifies otherwise.

Exception: UnitedHealthcare of California delegated PA reviews may allow the self‑administered product under the medical benefit.

Key Definitions and Terms

Positive clinical response — required documentation for continuation

Documentation requirementDocumentation of positive clinical response is required for continuation of therapy

Associated requirementsCimzia must be dosed per FDA labeling for the treated indication

Concurrent therapy restrictionPatient must not be receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication

Authorization durationContinuation authorizations are typically issued for 12 months when documentation requirements are met

Plaque psoriasis severity definition

Definition>= 3% body surface area (BSA) involvement or involvement of palmoplantar, facial, genital, or severe scalp

Clinical Background

Cimzia (certolizumab pegol) is a pegylated anti‑TNF biologic indicated for multiple inflammatory conditions including Crohn's disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and non‑radiographic axial spondyloarthritis with objective signs of inflammation, moderate‑to‑severe plaque psoriasis, and active polyarticular juvenile idiopathic arthritis in patients 2 years and older. The agent is described in the policy as certolizumab pegol (a TNF blocker) and coverage rules align use and dosing to the US FDA‑labeled regimens for each covered indication.

Diagnosis Codes and Claim Support

Documentation Required

ICD‑10 diagnosis codes provided to support authorizations

The policy includes extensive ICD‑10 diagnosis code lists that may be used to support prior authorization or coverage determinations; reference the policy coding tables when submitting PA requests.

Multiple ICD‑10 code blocks are provided per indication — include applicable codes in the PA/claim.

Documentation Required

Ensure documentation supports the ICD‑10 codes used in PA/claims

Documentation submitted with claims or prior authorization requests should support use of the listed ICD‑10 diagnosis codes (e.g., documentation of disease activity and site involvement for plaque psoriasis).

For plaque psoriasis include BSA or site involvement documentation when applicable (policy specifies ≥3% BSA or palmoplantar/facial/genital/severe scalp involvement).

Note

Policy Revision History

2026-02-01Policy revisionLatest

Replaced 'targeted immunomodulator' with 'systemic targeted immunomodulator'; added prescriber attestation requirement (prescriber must submit explanation) for inability to self‑administer; updated indication‑specific lists of systemic targeted immunomodulators (agents added, removed, or renamed) affecting combination‑therapy and prior‑treatment rules.

Note

Policy updates changed which agents count toward step‑therapy/prior therapy

The policy history documents specific agent additions, removals, and renamings that change which systemic targeted immunomodulators count as prior or concurrent therapies; verify the updated agent list in the current policy version when determining prior‑therapy status.

Examples: additions of Bimzelx, Sotyktu, Cosentyx, Taltz; removals such as Olumiant in some lists; Xeljanz renamed to Xeljanz/XR in lists.
These changes are material to step‑therapy and prior‑treatment determinations.

OpenPayer

Cimzia (Certolizumab Pegol)

Coverage and Medical Necessity Criteria

Initial Therapy Requirements by Indication

Continuation Therapy Requirements

Prior Treatment and Step Therapy Requirements

Applicable Coding

Prior Authorization, Documentation, and Prescriber Actions

Pharmacy vs Medical Benefit

Key Definitions and Terms

Clinical Background

Diagnosis Codes and Claim Support

Policy Revision History