By Counterforce Health Team in Cimzia (certolizumab pegol) —

Get Cimzia (Certolizumab Pegol) Covered by Humana in New York: Complete PA Guide with Appeals Process

Answer Box: Fastest Path to Cimzia Coverage with Humana in New York

Yes, Humana covers Cimzia (certolizumab pegol) in New York, but prior authorization is required. The fastest approval path: (1) Your prescriber submits a PA through Humana's provider portal with TB/hepatitis B screening results, diagnosis documentation, and proof of failed conventional therapy; (2) If denied, file an internal appeal within 65 days; (3) For continued denials, request a New York State external review through DFS within 4 months. Start today: Ask your doctor to check Humana's Prior Authorization Search Tool for your specific plan's Cimzia requirements.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Medical Necessity Criteria
  5. Cost and Financial Assistance
  6. Denials and Appeals in New York
  7. Renewal Requirements
  8. Specialty Pharmacy Network
  9. Troubleshooting Common Issues
  10. FAQ: Most Common Questions

Coverage Basics

Is Cimzia Covered by Humana?

Cimzia is included on Humana's 2024-2025 Medicare Advantage and Part D formularies, but it's classified as a specialty tier (Tier 5) medication requiring prior authorization. The drug is also covered under Humana commercial plans in New York, subject to similar PA requirements.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Humana PA Portal Humana Provider
Step Therapy Must try preferred TNF inhibitors first Step Therapy List Humana 2025
Specialty Pharmacy CenterWell or approved network Specialty Pharmacy Humana
TB/HBV Screening Required before approval FDA Label Requirements Cimzia Safety Info

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Provider checks plan requirements (Day 0)
  2. Complete required screening (Days 1-7)
    • Order TB testing (IGRA or TST) within 12 months
    • Obtain hepatitis B panel (HBsAg, anti-HBc, anti-HBs)
    • Document baseline CBC, liver function tests
  3. Gather clinical documentation (Days 1-5)
    • Specialist consultation notes (rheumatology, gastroenterology, or dermatology)
    • Prior therapy records with dates, doses, and failure reasons
    • Current disease activity measures
  4. Submit PA request (Day 7-10)
    • Online: CoverMyMeds portal or Availity
    • Fax: 502-508-9300
    • Phone (urgent): 1-866-488-5995 (Medicare) or 1-866-421-5663 (commercial)
  5. Track and follow up (Days 10-14)
    • Standard decisions: 72 hours for non-urgent, 24 hours for expedited
    • Check status via provider portal or call

Clinician Corner: Medical Necessity Letter Checklist

Your PA submission should include:

  • Diagnosis and severity: ICD-10 code with clinical findings (joint counts, imaging, endoscopy results)
  • Prior treatments: Specific drugs tried, doses, duration, and documented failure/intolerance
  • Clinical rationale: Why Cimzia is appropriate over preferred alternatives
  • Safety screening: TB and hepatitis B results with interpretation
  • Monitoring plan: Follow-up schedule and safety assessments
Tip: Include exact quotes from clinical notes showing inadequate response to step therapy requirements. For example: "Patient experienced only 20% improvement in joint count after 3 months of adalimumab 40mg every other week."

Timeline and Urgency

Standard Processing Times

  • Prior authorization decision: 72 hours (standard), 24 hours (expedited)
  • Internal appeal: 30 days for Medicare Part C, 7 days for Part D
  • External appeal (New York): 30 days for standard, 72 hours for expedited

When to Request Expedited Review

Request expedited processing if:

  • Patient has active, severe disease requiring immediate treatment
  • Delay would cause serious deterioration in health
  • Current therapy is failing and causing complications

Contact Humana at 1-866-488-5995 for Medicare expedited requests.

Medical Necessity Criteria

Required Documentation for Approval

For Rheumatologic Conditions (RA, PsA, AS):

  • Confirmed diagnosis by rheumatologist
  • Inadequate response to ≥1 conventional DMARD (typically methotrexate)
  • Failure of ≥1 preferred TNF inhibitor or biosimilar
  • Current disease activity measures (DAS28, CDAI, or similar)

For Crohn's Disease:

  • Confirmed diagnosis with endoscopic or imaging evidence
  • Moderate to severe disease activity
  • Inadequate response to corticosteroids and immunomodulators
  • Documentation of disease complications if applicable

Safety Requirements (All Indications):

  • Negative TB screening (IGRA or TST) within 12 months
  • Hepatitis B screening with management plan if positive
  • No active serious infections
  • Appropriate vaccination status (no live vaccines during treatment)

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
Missing TB screening Submit test results IGRA or TST report within 12 months
Inadequate step therapy Document failures Prior auth records, clinic notes showing inadequate response
Non-preferred diagnosis Specialist confirmation Rheumatology/GI consultation with ICD-10 codes
Insufficient severity Objective measures Disease activity scores, imaging, lab results

Cost and Financial Assistance

Expected Costs with Humana

  • Medicare Part D: Typically 25% coinsurance on specialty tier
  • Commercial plans: Varies by plan design, often $150-500+ monthly copay
  • List price: Approximately $6,000 for maintenance pack (two 200mg syringes)

Savings Options

UCB Cimzia Support Programs:

  • Complete Savings Program: Up to $25,000 annually for eligible patients
  • Income-based assistance for uninsured patients
  • Free drug programs through patient assistance foundations

Through Specialty Pharmacies:

  • CenterWell Specialty financial counselors: 1-800-486-2668
  • Foundation grant applications and copay assistance enrollment

Denials and Appeals in New York

Appeals Playbook for Humana in New York

Level 1: Internal Appeal

  • Timeline: Must file within 65 days of denial notice
  • How to file: Online via MyHumana, phone 1-877-877-1051, or mail
  • Decision timeframe: 30 days (Medicare Part C), 7 days (Part D)

Level 2: New York State External Review

  • Who can file: Patient or provider after internal appeal denial
  • Timeline: Within 4 months of final internal denial
  • Cost: $25 fee (waived for Medicaid/financial hardship)
  • How to file: NY DFS External Appeal Portal
  • Decision: Binding on Humana if overturned

Expedited Appeals (Urgent Cases):

  • New York allows 72-hour expedited external appeals for urgent drug denials
  • 24-hour decision if serious health risk documented
  • Provider must attest to urgency with clinical justification
From Our Advocates: We've seen multiple Cimzia appeals succeed in New York when providers submitted detailed comparative effectiveness data showing why biosimilars weren't appropriate for that specific patient. The key was demonstrating patient-specific factors, not just general preferences.

When to Escalate to State Regulators

Contact the New York Department of Financial Services if:

  • Humana repeatedly delays decisions beyond required timeframes
  • Appeals are denied without proper medical review
  • You suspect inappropriate denial patterns

Contact Information:

Renewal Requirements

When to Re-authorize

  • Initial approval: Typically 6-12 months
  • Renewal timing: Submit 30 days before expiration
  • Required updates: Current disease activity, treatment response, any new safety concerns

What Changes Require New PA

  • Dose increases beyond approved regimen
  • New indications or diagnoses
  • Plan changes (including Medicare Part D plan switches)
  • Gaps in therapy >90 days

Specialty Pharmacy Network

Humana's Preferred Specialty Pharmacies

CenterWell Specialty Pharmacy (Humana-owned):

  • Phone: 1-800-486-2668
  • Ships nationwide including New York
  • Integrated with Humana benefits and PA system
  • Provides clinical support and financial assistance coordination

Other In-Network Options (verify with your specific plan):

  • CVS Specialty: 1-800-237-2767
  • Accredo: 1-844-516-3319
  • Optum Specialty Pharmacy

Patient Enrollment Process

  1. Prescription transfer: Provider sends Cimzia prescription to chosen specialty pharmacy
  2. Benefits verification: Pharmacy confirms Humana coverage and PA status
  3. Patient intake: Clinical assessment, administration training, financial counseling
  4. First shipment: Cold-chain delivery to home or clinic in New York
  5. Ongoing support: Refill management, adherence monitoring, side effect tracking
Note: Counterforce Health helps patients and providers navigate complex specialty pharmacy requirements by automating prior authorization documentation and appeals processes, reducing delays in getting medications like Cimzia approved and delivered.

Troubleshooting Common Issues

Portal and System Problems

If Humana's PA portal is down:

  • Use backup fax submission: 502-508-9300
  • Call provider services for urgent requests: 1-866-421-5663
  • Document submission attempts for appeal purposes

Missing Forms or Documentation:

Coverage Verification Issues

If coverage status is unclear:

  1. Call Humana member services with policy number and group information
  2. Verify current formulary status for your specific plan year
  3. Confirm in-network status of prescriber and specialty pharmacy

FAQ: Most Common Questions

Q: How long does Humana prior authorization take for Cimzia in New York? A: Standard PA decisions are made within 72 hours. Expedited requests (for urgent medical needs) are decided within 24 hours. Source: Humana PA Policy

Q: What if Cimzia is non-formulary on my Humana plan? A: Request a formulary exception with your PA submission. Include clinical justification for why formulary alternatives are inappropriate. New York external appeal rights apply if denied.

Q: Can I request an expedited appeal if Humana denies Cimzia? A: Yes, if delay would cause serious deterioration in health. New York allows 72-hour expedited external appeals for urgent drug denials, or 24 hours if serious health risk is documented.

Q: Does step therapy apply if I failed TNF inhibitors outside New York? A: Yes, documented failures from other states count toward Humana's step therapy requirements. Ensure your provider includes complete treatment history with dates and outcomes.

Q: What counts as "medical necessity" for Cimzia approval? A: FDA-approved indication, appropriate diagnosis severity, documented failure of preferred alternatives, and proper safety screening (TB/hepatitis B testing). Source: Humana Coverage Policy

Q: Why was my prescription transferred to a specialty pharmacy? A: Cimzia requires special handling due to cold-chain storage requirements and complex administration. Humana requires specialty pharmacy dispensing for most biologic medications to ensure proper patient support and safety monitoring.

Q: How much will Cimzia cost with Humana coverage? A: Costs vary by plan type. Medicare Part D typically requires 25% coinsurance (specialty tier), while commercial plans may have fixed copays ranging from $150-500+ monthly. UCB offers copay assistance up to $25,000 annually for eligible patients.

Q: What happens if I switch Humana plans mid-year? A: You'll need a new PA for the new plan, even if both cover Cimzia. Submit the request 30 days before your plan change effective date to avoid gaps in coverage.

Counterforce Health specializes in turning insurance denials into successful appeals by identifying specific denial reasons and crafting evidence-backed rebuttals aligned with each payer's own policies. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements for medications like Cimzia, reducing approval times and improving access to necessary treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or visit the NY Department of Financial Services consumer assistance page.

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