By Counterforce Health Team in Cimzia (certolizumab pegol) —

Getting Cimzia (Certolizumab Pegol) Covered by Cigna in North Carolina: Complete Prior Authorization Guide

Quick Answer: Cigna Coverage for Cimzia in North Carolina

Cigna requires prior authorization for Cimzia (certolizumab pegol) in North Carolina. You'll need: (1) FDA-approved diagnosis like Crohn's disease or rheumatoid arthritis, (2) documented failure/intolerance to conventional therapies and usually one preferred TNF inhibitor, and (3) TB/hepatitis B screening results. First step today: Have your specialist submit Cigna's PA form with complete medical records. If denied, North Carolina offers robust external review through Smart NC (1-855-408-1212). Appeals must be filed within 180 days internally, then 120 days for external review.

Table of Contents

Cigna's Policy Overview

Cigna Healthcare covers Cimzia through its specialty drug benefit, typically managed by Express Scripts or Accredo. The medication requires prior authorization across all Cigna plan types—HMO, PPO, and Medicare Advantage—in North Carolina.

Coverage Basics:

  • Formulary status: Usually Tier 4 or 5 specialty drug
  • Prior authorization: Required for all indications
  • Specialty pharmacy: Must be filled through designated specialty pharmacy
  • Initial approval: Up to 12 months with annual renewal
Note: Self-funded employer plans may have different requirements. Check your specific plan documents or contact Cigna member services at the number on your ID card.

Medical Necessity Requirements

Cigna considers Cimzia medically necessary when specific clinical criteria are met:

FDA-Approved Indications

  • Crohn's disease (moderate to severe) in adults
  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Non-radiographic axial spondyloarthritis
  • Plaque psoriasis
  • Polyarticular juvenile idiopathic arthritis

Diagnosis Documentation

Your specialist must provide:

  • ICD-10 codes for your specific condition
  • Disease severity assessment with objective measures
  • Treatment goals and expected outcomes
  • Contraindications to preferred alternatives

Step Therapy & Preferred Alternatives

Cigna typically requires step therapy before approving Cimzia:

Required Prior Therapies

For Rheumatoid Arthritis:

  • Methotrexate (unless contraindicated)
  • At least one preferred TNF inhibitor (adalimumab or etanercept)

For Crohn's Disease:

  • Aminosalicylates, corticosteroids, or immunomodulators
  • One preferred anti-TNF agent

Medical Exceptions

Step therapy can be bypassed if you have:

  • Documented contraindications to preferred agents
  • Previous intolerance with specific adverse events
  • Clinical urgency requiring immediate Cimzia initiation
Tip: Counterforce Health specializes in turning insurance denials into targeted appeals by identifying the specific denial basis and crafting point-by-point rebuttals aligned to your plan's own rules.

Dosing Limits & Quantity Restrictions

Cigna covers standard Cimzia dosing regimens:

Phase Dose Frequency Quantity Limit
Loading 400 mg Weeks 0, 2, 4 6 injections/month
Maintenance 200 mg Every 2 weeks 2 injections/month
Maintenance 400 mg Every 4 weeks 2 injections/month

Doses exceeding these limits require additional clinical justification and may trigger utilization review.

Required Screening & Diagnostics

Before Cimzia approval, Cigna requires documentation of:

Tuberculosis Screening

  • QuantiFERON-TB Gold or tuberculin skin test
  • Chest X-ray (mandatory if TB screening positive)
  • Treatment completion for latent TB before Cimzia initiation

Hepatitis B Screening

  • Hepatitis B surface antigen
  • Hepatitis B core antibody
  • Management plan if positive

Additional Tests

  • Complete blood count
  • Liver function tests
  • Assessment of active infections
Important: All screening must be completed within 12 months of PA submission. Outdated results may cause delays.

Specialty Pharmacy Requirements

Cigna requires Cimzia to be dispensed through designated specialty pharmacies:

Preferred Networks:

  • Accredo (most common)
  • Express Scripts specialty pharmacy
  • Other Cigna-contracted specialty pharmacies

Site of Care:

  • Self-injection at home is preferred and typically required
  • Infusion center administration requires additional medical justification
  • Some plans mandate home delivery after initial doses

Contact Cigna member services to confirm your specific specialty pharmacy network.

Evidence Documentation

Medical Necessity Letter Checklist

Your specialist should include:

Clinical History:

  • Diagnosis with onset date and severity markers
  • Complete prior therapy history (medications, doses, duration, outcomes)
  • Specific reasons for discontinuation (inefficacy, adverse events)
  • Current disease activity measures

Supporting Evidence:

  • Relevant FDA labeling for your indication
  • Professional society guidelines (ACR for RA, ACG for Crohn's)
  • Peer-reviewed literature supporting Cimzia use
  • Laboratory and imaging results

Treatment Plan:

  • Proposed dosing regimen with rationale
  • Monitoring plan and safety measures
  • Expected clinical outcomes and timeframe

Appeals Process in North Carolina

If Cigna denies your Cimzia request, North Carolina offers strong appeal protections:

Internal Appeals (Cigna)

  1. Timeline: File within 180 days of denial
  2. Process: Submit written appeal with additional clinical evidence
  3. Decision: Cigna must respond within 30 days (expedited: 72 hours)

External Review (Smart NC)

If internal appeals fail:

  1. Eligibility: Must exhaust Cigna's internal process first
  2. Timeline: File within 120 days of final internal denial
  3. Contact: Smart NC at 1-855-408-1212
  4. Decision: Independent Review Organization decides within 45 days (expedited: 72 hours)
  5. Binding: IRO decisions are binding on Cigna
From our advocates: We've seen many Cimzia denials overturned at external review when patients provide comprehensive evidence of step therapy completion and clear documentation of medical necessity. The key is organizing all prior therapy records and getting strong specialist support letters.

Expedited Reviews

Available when delays could seriously jeopardize your health:

  • Internal expedited: 72 hours
  • External expedited: 72 hours (urgent drug denials: 24-72 hours)

Smart NC can help you prepare your external review request and gather supporting documentation.

Cost Assistance Options

Manufacturer Support

  • UCB Patient Support Program: May cover copays up to annual limits
  • Eligibility: Commercial insurance required; income restrictions may apply
  • Contact: Check UCB's official website for current programs

Foundation Assistance

  • Patient Advocate Foundation
  • HealthWell Foundation
  • Chronic Disease Fund

State Programs

North Carolina's Medicaid expansion (effective 2024) may provide additional coverage options for eligible residents.

FAQ

How long does Cigna prior authorization take in North Carolina? Standard PA decisions: 72 hours for formulary exceptions, up to 15 days for standard medical PA. Expedited requests: 24 hours.

What if Cimzia is non-formulary on my Cigna plan? Request a formulary exception through your prescriber. Provide documentation that preferred alternatives were ineffective or inappropriate.

Can I request an expedited appeal? Yes, if delays would seriously jeopardize your health. Both Cigna and Smart NC offer expedited review processes.

Does step therapy apply if I failed TNF inhibitors in another state? Medical records from any state showing documented failure/intolerance should satisfy step therapy requirements. Ensure complete documentation transfer.

What happens if Smart NC overturns Cigna's denial? Cigna must provide coverage within 3 business days of the IRO's favorable decision.

How much does Cimzia cost without insurance? UCB's list price is approximately $5,999 for a two-injection maintenance pack. Patient assistance programs may help reduce costs.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters and plan policies, then identifies the specific denial basis and drafts point-by-point rebuttals aligned to your plan's own rules, pulling the right clinical evidence and FDA citations to support your case.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with North Carolina insurance appeals, contact Smart NC at 1-855-408-1212.

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