CurrentUnitedHealthcarePolicy N/A

Cimzia (certolizumab) prior authorization

Defines prior authorization, initial authorization, and reauthorization criteria for Cimzia (certolizumab) across multiple indicated inflammatory conditions for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyCimzia (certolizumab) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 15, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis and, for reauthorization, evidence of positive clinical response; confirm patient is not receiving another systemic targeted immunomodulator for the same indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

multipleindications

prohibitedcombination therapy

Prior Authprogram type

Sep 2025labeling cited

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Initial Therapy - Crohn's disease

Initial Authorization for Crohn's disease: Covered when ALL of the following are met

Crohn's initial: (1) Diagnosis of moderately to severely active Crohn's disease

Crohn's conventional therapy: (2) Patient has had an inadequate response to conventional therapies (examples include anti-inflammatory drugs, corticosteroids, or oral immunosuppressive agents)

Crohn's no combination: (3) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Authorization will be issued for 12 months

Initial Therapy - Rheumatoid arthritis

Initial Authorization for Rheumatoid arthritis: Covered when BOTH are met

RA diagnosis: (1) Diagnosis of moderately to severely active rheumatoid arthritis

RA no combination: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Authorization will be issued for 12 months

Initial Therapy - Psoriatic arthritis

Initial Authorization for Psoriatic arthritis: Covered when BOTH are met

PsA diagnosis: (1) Diagnosis of active psoriatic arthritis

PsA no combination: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Authorization will be issued for 12 months

Initial Therapy - Ankylosing spondylitis / nraxSpA

Initial Authorization for Ankylosing spondylitis / non-radiographic axial spondyloarthritis: Covered when BOTH are met

SpA diagnosis: (1) Diagnosis of active ankylosing spondylitis or non-radiographic axial spondyloarthritis

SpA no combination: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Authorization will be issued for 12 months

Initial Therapy - Plaque psoriasis

Initial Authorization for Plaque psoriasis: Covered when BOTH are met

PS diagnosis: (1) Diagnosis of moderate to severe plaque psoriasis

PS no combination: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Authorization will be issued for 12 months

Reauthorization - All indications

Reauthorization for multiple indications: Covered when ALL of the following are met

Reauth response: (1) Documentation of positive clinical response to Cimzia therapy

Reauth no combination: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Authorization will be issued for 12 months

Initial Therapy - Plaque Psoriasis

Covered when ALL of the following are met:

Plaque psoriasis initial: (1) Diagnosis of moderate to severe plaque psoriasis

Combination therapy exclusion: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Examples listed in policy (e.g., adalimumab, bimekizumab, secukinumab, etanercept, tildrakizumab, apremilast, risankizumab, brodalumab, deucravacitinib, ixekizumab, guselkumab, ustekinumab)

Reauthorization - Plaque Psoriasis

Covered on reauthorization when ALL of the following are met:

Positive clinical response: (1) Documentation of positive clinical response to Cimzia therapy

Combination therapy exclusion: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Examples listed in policy

Initial Therapy - pJIA

Covered when ALL of the following are met:

pJIA diagnosis: (1) Diagnosis active polyarticular juvenile idiopathic arthritis

Authorization will be issued for 12 months

Combination therapy exclusion: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Examples listed in policy (e.g., adalimumab, etanercept, baricitinib, abatacept, upadacitinib, golimumab, tofacitinib)

Reauthorization - pJIA

Covered on reauthorization when ALL of the following are met:

Positive clinical response: (1) Documentation of positive clinical response to Cimzia therapy

Combination therapy exclusion: (2) Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication

Authorization will be issued for 12 months

Use of Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication is excluded from approval. Examples of systemic targeted immunomodulators listed in the policy include adalimumab, etanercept (Enbrel), bimekizumab (Bimzelx), secukinumab (Cosentyx), tildrakizumab (Ilumya), apremilast (Otezla), risankizumab (Skyrizi), brodalumab (Siliq), deucravacitinib (Sotyktu), ixekizumab (Taltz), guselkumab (Tremfya), ustekinumab, baricitinib (Olumiant), abatacept (Orencia), upadacitinib (Rinvoq), golimumab (Simponi), and tofacitinib (Xeljanz/XR).

Initial Authorization Criteria by Indication

Initial therapy - Crohn's disease

Initial authorization rules for Crohn's disease

CD initial: Diagnosis of moderately to severely active Crohn's disease; inadequate response to conventional therapies; not receiving Cimzia with another systemic targeted immunomodulator for same indication

Authorization for 12 months

Initial therapy - Rheumatoid arthritis

Initial authorization rules for RA

RA initial: Diagnosis of moderately to severely active rheumatoid arthritis; not receiving Cimzia with another systemic targeted immunomodulator for same indication

Authorization for 12 months

Initial therapy - Psoriatic arthritis

Initial authorization rules for PsA

PsA initial: Diagnosis of active psoriatic arthritis; not receiving Cimzia with another systemic targeted immunomodulator for same indication

Authorization for 12 months

Initial therapy - Ankylosing spondylitis / nraxSpA

Initial authorization rules for AS/nraxSpA

SpA initial: Diagnosis of active ankylosing spondylitis or non-radiographic axial spondyloarthritis; not receiving Cimzia with another systemic targeted immunomodulator for same indication

Authorization for 12 months

Initial therapy - Plaque psoriasis

Initial authorization rules for plaque psoriasis

PS initial: Diagnosis of moderate to severe plaque psoriasis; not receiving Cimzia with another systemic targeted immunomodulator for same indication

Authorization for 12 months

Initial Therapy

Initial authorization conditions by indication

Plaque psoriasis initial: Diagnosis of moderate to severe plaque psoriasis AND patient not receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication

pJIA initial: Diagnosis of active polyarticular juvenile idiopathic arthritis AND patient not receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication

Authorization will be issued for 12 months

Reauthorization / Continuation Criteria

Continuation / Reauthorization Criteria

Reauthorization / Continuation — Covered when ALL of the following are met:

Continuation Therapy

Documentation of positive clinical response to Cimzia therapy (e.g., decreased symptom severity, improved objective measures, or documented clinical assessment).
For Crohn's disease: documentation of symptomatic improvement or objective evidence of disease control (endoscopic, radiologic, or laboratory markers) while on Cimzia.
For rheumatoid arthritis: documentation of improvement in signs and symptoms of RA (e.g., reduced joint swelling/tenderness, improved function, decreased inflammatory markers) on Cimzia therapy.
For psoriatic arthritis: documentation of clinical improvement in joint symptoms and/or skin disease while on Cimzia.
For axial spondyloarthritis/ankylosing spondylitis: documentation of reduced spinal pain/stiffness or improved mobility and/or inflammatory markers while on Cimzia.
For plaque psoriasis: documentation of improvement in plaque severity (physician assessment, body surface area, or validated psoriasis severity scores) on Cimzia.
If combination therapy is used, documentation must state concurrent use of allowed concomitant medications (e.g., methotrexate) and rationale for combination therapy.
Program automation and supply limits: requests must conform to program-defined quantity limits and supply intervals; approvals through automated prior authorization will follow configured supply limits unless clinical documentation justifies an override.

Documentation Required

Reauthorization documentation — Documentation required

For reauthorization, clinical documentation demonstrating positive clinical response to Cimzia therapy is required. Absence of documentation of positive clinical response may trigger denial at reauthorization.

Applicable to: Initial Authorization for Crohn's disease, Rheumatoid arthritis, Psoriatic arthritis, Axial spondyloarthritis/AS, and Plaque psoriasis
Reauthorization response documentation must include objective or clinician-assessed evidence of improvement
Combination therapy documentation: list concurrent immunomodulators and clinical rationale
Program automation and supply limits: approvals may be processed automatically within configured limits; requests exceeding limits require clinical justification

Prior Authorization

Reauthorization — Reauthorization requirement

Cimzia will be approved at reauthorization only when documentation of positive clinical response to therapy is provided.

Ensure documentation addresses the specific condition treated (see individual condition requirements)
Failure to provide adequate reauthorization documentation may result in denial or request for additional information

What Providers Must Do

Prior Authorization

Prior authorization: Crohn's disease — diagnosis and prior therapy required

Submit a prior authorization request showing a diagnosis of moderately to severely active Crohn's disease and evidence the patient had an inadequate response to conventional therapies.

Conventional therapy examples in the policy include anti-inflammatory drugs, corticosteroids, or oral immunosuppressive agents.
Authorization will be issued for 12 months.

Prior Authorization

Prior authorization: Rheumatoid arthritis — diagnosis and no concurrent targeted immunomodulator

For initial authorization in rheumatoid arthritis, submit a prior authorization demonstrating a diagnosis of moderately to severely active RA and that the patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication.

Authorization will be issued for 12 months.

Prior Authorization

Prior authorization: Psoriatic arthritis — diagnosis and no concurrent targeted immunomodulator

For initial authorization in psoriatic arthritis, submit a prior authorization documenting a diagnosis of active PsA and that the patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication.

Authorization will be issued for 12 months.

Prior Authorization

Prior authorization: Ankylosing spondylitis/nraxSpA — diagnosis and no concurrent targeted immunomodulator

For initial authorization in ankylosing spondylitis or non-radiographic axial spondyloarthritis, submit a prior authorization documenting the diagnosis and that the patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication.

Authorization will be issued for 12 months.

Prior Authorization

Prior authorization: Plaque psoriasis — diagnosis and no concurrent targeted immunomodulator

For initial authorization for moderate to severe plaque psoriasis, submit a prior authorization documenting the diagnosis and that the patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication.

Authorization will be issued for 12 months.

Prior Authorization

Initial authorization: verify diagnosis and absence of combination therapy

Initial authorization requests must include documentation of the covered diagnosis (e.g., moderate to severe plaque psoriasis or active polyarticular juvenile idiopathic arthritis) and confirmation the patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication.

Authorization will be issued for 12 months.

Step Therapy

Document prior inadequate response to conventional therapies for Crohn's disease

For Crohn's disease initial approval, provide evidence of inadequate response to conventional therapies (examples listed in policy) as this is required for approval.

Examples of conventional therapies: anti-inflammatory drugs, corticosteroids, or oral immunosuppressive agents.

Billing Rule

Program automation and possible supply limits

Some programs may use automated approval or prior medication/claim history to approve initial or reauthorization requests; supply limits may apply.

UnitedHealthcare may approve based solely on previous claim/medication history, diagnosis codes, and/or claim logic.
Supply limits may be in place.

Documentation Required

Document absence of concomitant systemic targeted immunomodulator

Provide documentation that the patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication; combination therapy exclusion applies to both initial and reauthorization requests.

Policy lists examples of systemic targeted immunomodulators (e.g., adalimumab, etanercept, upadacitinib, risankizumab, guselkumab, ustekinumab, etc.).
Requests with concurrent use for the same indication will not meet criteria and risk denial.

Denial Risk

Denial risk: missing conventional therapy failure documentation for Crohn's

If the initial Crohn's disease request lacks documentation of an inadequate response to conventional therapies, the request may be denied.

Denial Risk

Requests using Cimzia concurrently with another targeted immunomodulator will be denied

Requests where the patient is receiving Cimzia in combination with another systemic targeted immunomodulator for the same indication will not meet the combination‑therapy criterion and will be denied.

Step	Requirement
1
Patient has had an inadequate response to conventional therapies (examples include anti-inflammatory drugs, corticosteroids, or oral immunosuppressive agents). Authorization will be issued for 12 months.
Patient is not receiving Cimzia in combination with another systemic targeted immunomodulator for treatment of the same indication (examples listed in policy).

Automation/Process	Notes
Automated approval and re-approval processes may be used
UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic; use of automated processes varies by program/therapeutic class. Supply limits may be in place.

OpenPayer

Cimzia (certolizumab) prior authorization

Coverage Criteria for Cimzia (certolizumab)

Initial Authorization Criteria by Indication

Reauthorization / Continuation Criteria

What Providers Must Do

Key Definitions and Class

Background

Step Therapy and Automation