By Counterforce Health Team in Cimzia (certolizumab pegol) —

Do You Qualify for Cimzia Coverage by Aetna in New York? Decision Tree & Next Steps

Answer Box: Getting Cimzia Covered by Aetna in New York

Yes, you can get Cimzia (certolizumab pegol) covered by Aetna CVS Health in New York with proper documentation. Most approvals require: confirmed diagnosis (Crohn's disease, rheumatoid arthritis, psoriasis, or ankylosing spondylitis), completed TB/hepatitis B screening, documented failure of preferred alternatives, and specialist prescription. First step today: Contact your prescribing specialist to initiate prior authorization through the Availity portal or CVS Caremark system. If denied, New York offers robust external appeal rights through the Department of Financial Services within 4 months.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Document Checklist
  4. If "Possibly Eligible" - Next Steps
  5. If "Not Yet" - Alternative Paths
  6. If Denied - Appeal Path Chooser
  7. Coverage at a Glance
  8. Common Denial Reasons & Fixes
  9. FAQ
  10. Resources & Support

How to Use This Guide

This decision tree helps you determine your likelihood of getting Cimzia covered by Aetna CVS Health in New York. Work through each section in order, gathering the required documentation as you go.

Important: Cimzia requires prior authorization from Aetna, typically processed within 30-45 days for standard requests. Submit requests at least two weeks in advance to avoid treatment delays.

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

Likely Eligible if you have:

  • Moderate to severe Crohn's disease (adults)
  • Rheumatoid arthritis with inadequate response to conventional therapy
  • Active psoriatic arthritis
  • Active ankylosing spondylitis
  • Non-radiographic axial spondyloarthritis
  • Moderate to severe plaque psoriasis
  • Polyarticular juvenile idiopathic arthritis (age 4+)

Step 2: Check Required Screenings

Must be completed within 12 months:

  • Tuberculosis screening: PPD skin test or IGRA blood test (QuantiFERON)
  • Hepatitis B screening: HBsAg, anti-HBc, and anti-HBs tests
  • Complete blood count and liver function tests
Note: If TB screening is positive (≥5mm induration), you'll need treatment for latent TB infection before starting Cimzia.

Step 3: Prior Therapy Requirements

Aetna typically requires documented failure, intolerance, or contraindication to:

  • Conventional DMARDs (methotrexate, sulfasalazine) for inflammatory arthritis
  • Corticosteroids or immunomodulators for Crohn's disease
  • Preferred biosimilars (adalimumab biosimilars, infliximab biosimilars) per step therapy

Step 4: Specialist Requirement

Must be prescribed by or in consultation with:

  • Rheumatologist (RA, AS, PsA, nr-axSpA, JIA)
  • Gastroenterologist (Crohn's disease)
  • Dermatologist (psoriasis, psoriatic arthritis)

If "Likely Eligible" - Document Checklist

Required Documentation

  • Diagnosis confirmation with ICD-10 codes and severity assessment
  • TB screening results (date, test type, result, action taken if positive)
  • Hepatitis B screening results (all three tests)
  • Prior therapy documentation showing failures/intolerance with dates and reasons
  • Specialist prescription with clinical rationale
  • Current labs (CBC, liver function tests)

Submission Process

  1. Provider submits via Availity portal or EMR integration
  2. Include medical records supporting diagnosis and prior treatments
  3. Complete all form sections - incomplete submissions cause delays
  4. Expected timeline: 30-45 days for standard review, 72 hours for urgent requests

Counterforce Health helps patients and clinicians streamline this process by automatically generating evidence-backed prior authorization requests that align with Aetna's specific criteria, reducing approval time and improving success rates.

If "Possibly Eligible" - Next Steps

Missing Elements to Address

If diagnosis needs confirmation:

  • Schedule specialist consultation
  • Request disease activity scores or imaging studies
  • Document symptom severity and functional impact

If screenings incomplete:

  • Order TB and hepatitis B tests immediately
  • Allow 1-2 weeks for results
  • Address any positive findings before resubmitting

If prior therapy unclear:

  • Gather pharmacy records showing filled prescriptions
  • Document specific reasons for discontinuation
  • Note contraindications or allergies

Timeline to Re-apply

  • 2-4 weeks to complete missing tests and documentation
  • Submit new PA request once all requirements met
  • Track deadlines - some conditions may worsen without timely treatment

If "Not Yet" - Alternative Paths

Formulary Exception Process

If Cimzia isn't preferred, request a formulary exception through CVS Caremark:

  • Submit clinical rationale for Cimzia over preferred alternatives
  • Document unique patient factors (allergies, prior responses)
  • Peer-to-peer review available if initially denied

Step Therapy Override

Required documentation:

  • Medical necessity for skipping preferred agents
  • Contraindications to step therapy requirements
  • Clinical urgency factors

Alternative Treatments to Discuss

Other anti-TNF options:

  • Adalimumab biosimilars (Amjevita, Cyltezo)
  • Infliximab biosimilars (Inflectra, Renflexis)
  • Etanercept (Enbrel)

Different mechanism drugs:

  • Ustekinumab (Stelara) for Crohn's/psoriasis
  • Risankizumab (Skyrizi) for psoriasis
  • Vedolizumab (Entyvio) for Crohn's disease

If Denied - Appeal Path Chooser

Level 1: Internal Appeal with Aetna

Timeline: Must file within 60-65 days of denial notice Decision time: 30 days standard, 72 hours expedited Submit to: Aetna member portal or mail address on denial letter

Required documents:

  • Original denial letter
  • Additional medical records
  • Physician letter of medical necessity
  • Updated clinical information

Level 2: Peer-to-Peer Review

When to use: After internal appeal denial Process: Your doctor speaks directly with Aetna medical director Timeline: Scheduled within 5-10 business days Outcome: Can result in immediate approval or proceed to external review

Level 3: New York External Appeal

Timeline: Must file within 4 months of final internal denial Decision time: 30 days standard, 72 hours expedited Cost: Up to $25 (waived for Medicaid or financial hardship) Submit to: New York Department of Financial Services

Key advantage: External appeals in New York are binding on insurers and have strong consumer protections.

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Required for all requests Aetna Precertification List
Formulary Tier Specialty tier (high copay) CVS Caremark Drug Guide
Step Therapy Biosimilars may be preferred Plan-specific formulary
Quantity Limits Maintenance dosing restrictions Aetna Quantity Limits
Site of Care CVS Specialty Pharmacy required CVS Specialty
Age Limits Varies by indication (JIA: 4+ years) FDA prescribing information

Common Denial Reasons & Fixes

Denial Reason How to Overturn
"Missing TB screening" Submit PPD or IGRA results within 12 months
"Step therapy not met" Document biosimilar failures or contraindications
"Not medically necessary" Provide specialist letter with clinical guidelines
"Experimental/investigational" Submit FDA approval documentation
"Quantity exceeded" Justify dosing with weight/severity factors

From our advocates: We've seen many Cimzia denials overturned when providers include specific failure details for preferred alternatives. Rather than just stating "patient failed methotrexate," document the exact timeline, doses tried, and specific adverse effects or lack of efficacy. This concrete evidence often satisfies step therapy requirements and medical necessity criteria.

FAQ

How long does Aetna prior authorization take for Cimzia in New York? Standard requests: 30-45 days. Expedited requests (urgent medical need): 72 hours. Submit at least 2 weeks before needed start date.

What if Cimzia isn't on my Aetna formulary? Request a formulary exception through CVS Caremark. Provide clinical rationale for why Cimzia is medically necessary over covered alternatives.

Can I get expedited appeals in New York? Yes. Both Aetna internal appeals and New York external appeals offer expedited review (72 hours) when your health could be seriously jeopardized by delays.

Does step therapy apply if I tried biosimilars outside New York? Yes, documented failures from any location count toward step therapy requirements. Ensure you have pharmacy records and clinical notes from the treating provider.

What's the success rate for Cimzia appeals in New York? New York's external appeal program has historically favored consumers when proper medical evidence is provided. The state's consumer-friendly laws and independent medical review process give patients strong protections.

Who pays for Cimzia if my appeal succeeds? Aetna must cover the medication retroactively and refund your external appeal filing fee (if applicable) when the external reviewer overturns their denial.

Resources & Support

Free Appeal Assistance

Community Health Advocates: 888-614-5400

  • Free help with Aetna appeals and denials
  • Available in 7+ languages
  • Assists with documentation and filing

Official Resources

Financial Support

  • UCB Patient Support: Cimzia manufacturer assistance programs
  • Good Days Foundation: Copay assistance for chronic conditions
  • New York State Medicaid: Coverage for eligible low-income residents

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed submissions that address each payer's specific requirements. Our platform helps patients and providers navigate complex prior authorization and appeals processes more effectively.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan benefits and medical circumstances. Always consult your healthcare provider and insurance plan documents for personalized guidance. For official appeal assistance in New York, contact Community Health Advocates at 888-614-5400 or the New York Department of Financial Services consumer helpline.

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