Getting Cimzia (Certolizumab Pegol) Covered by UnitedHealthcare in Illinois: Prior Authorization, Appeals & Forms
Quick Answer: Getting Cimzia Covered by UnitedHealthcare in Illinois
UnitedHealthcare requires prior authorization for Cimzia (certolizumab pegol) in Illinois. You'll need documentation of diagnosis (Crohn's, RA, etc.), tuberculosis/hepatitis B screening, and evidence of failed first-line treatments. Submit through the UnitedHealthcare provider portal with complete clinical documentation. If denied, you have 180 days for internal appeals and can request external review through Illinois Department of Insurance within 30 days of final denial.
First step today: Have your doctor gather TB/HBV screening results, diagnosis documentation, and prior treatment records before submitting the PA request.
Table of Contents
- UnitedHealthcare Plan Types in Illinois
- Cimzia Formulary Status & Tiers
- Prior Authorization Requirements
- Specialty Pharmacy Setup
- Cost-Sharing & Coverage
- Submission Process
- Appeals Process for Illinois
- Common Denial Reasons & Solutions
- FAQ
UnitedHealthcare Plan Types in Illinois
UnitedHealthcare offers several plan types in Illinois, each with different rules for accessing Cimzia:
Commercial Plans (HMO/PPO/EPO)
- All require prior authorization for Cimzia
- HMOs may require PCP referral to rheumatologist/gastroenterologist
- PPOs offer more pharmacy network flexibility
- EPOs require in-network use without PCP referrals
Illinois Medicaid Plans
- Cimzia listed as non-preferred, requiring PA
- Minimal or no copays for eligible members
- May require trying preferred TNF inhibitors first
Medicare Advantage
- Specialty tier placement (Tier 5)
- Significant coinsurance applies
- Subject to Medicare Part D coverage gap
Cimzia Formulary Status & Tiers
| Plan Type | Formulary Tier | Typical Cost-Share | Prior Auth Required |
|---|---|---|---|
| Commercial HMO/PPO | Specialty (Tier 4-5) | 20-50% coinsurance or $150-500 copay | Yes |
| Illinois Medicaid | Non-preferred | $0-5 copay | Yes |
| Medicare Advantage | Specialty (Tier 5) | 25-33% coinsurance | Yes |
Cimzia is placed in the highest specialty tier across UnitedHealthcare plans due to its high cost (approximately $5,999 for a two-syringe maintenance pack). The drug faces competition from preferred biosimilar alternatives for other TNF inhibitors, though no biosimilars exist for certolizumab pegol specifically.
Prior Authorization Requirements
Coverage at a Glance
| Requirement | What It Means | Where to Find It |
|---|---|---|
| FDA-approved diagnosis | Crohn's disease, RA, PsA, AS, plaque psoriasis, or polyarticular JIA | UnitedHealthcare Cimzia Policy |
| TB/HBV screening | Complete within 12 months of starting | FDA Cimzia Label |
| Step therapy | 3-month trial of non-biologic DMARD or prior TNF inhibitor | PA Medical Necessity Form |
| Specialist prescriber | Rheumatologist, gastroenterologist, or dermatologist | UnitedHealthcare Policy |
| No combination therapy | Cannot use with other biologics/targeted immunomodulators | UnitedHealthcare Policy |
Step-by-Step: Fastest Path to Approval
- Complete Safety Screening (Patient + Clinic)
- TB blood test or skin test within 12 months
- Hepatitis B surface antigen, core antibody, surface antibody tests
- Chest X-ray to rule out active TB
- Document Treatment History (Clinic)
- For RA/PsA: 3-month trial of methotrexate, leflunomide, sulfasalazine, or hydroxychloroquine
- For Crohn's: Prior use of adalimumab, infliximab, or other preferred agents
- Include specific dates, doses, and reasons for discontinuation
- Gather Clinical Evidence (Clinic)
- Elevated inflammatory markers (CRP, ESR)
- Disease activity scores (DAS28, CDAI, PASI)
- Imaging or endoscopy results showing active disease
- Submit PA Request (Provider)
- Use UnitedHealthcare provider portal or PA form
- Include all documentation and medical necessity letter
- Mark urgent if clinically appropriate (72-hour response)
- Follow Up (Patient + Clinic)
- Track submission through provider portal
- Standard response within 15 days, urgent within 72 hours
- Contact UnitedHealthcare if no response by deadline
Specialty Pharmacy Setup
UnitedHealthcare routes Cimzia through OptumRx specialty pharmacy network. Once PA is approved:
Patient Enrollment Process
- OptumRx contacts patient directly for enrollment
- Verify insurance coverage and copay amount
- Schedule home delivery or arrange retail pickup
- Set up automatic refills for maintenance therapy
Key Setup Steps
- Confirm shipping address and delivery preferences
- Review injection training materials or schedule nurse visit
- Understand refrigeration and storage requirements
- Set up copay assistance if eligible (commercial plans only)
Tip: OptumRx typically provides 30-day supplies for specialty medications. Ask about 90-day fills if your plan allows to reduce frequent reorders.
Cost-Sharing & Coverage
Commercial Plans
- Specialty tier: 20-50% coinsurance or fixed copay ($150-500)
- Annual out-of-pocket maximums apply
- High-deductible plans: full cost until deductible met
Cost-Saving Options
- UCB CIMplicity program: copay assistance for eligible commercial patients
- Patient assistance programs for uninsured/underinsured
- Illinois pharmaceutical assistance programs (verify eligibility)
Important: Copay assistance cannot be used with government insurance (Medicaid, Medicare).
Submission Process
Clinician Corner: Medical Necessity Letter Checklist
Your medical necessity letter should include:
- Diagnosis: Specific condition with ICD-10 codes
- Disease severity: Objective measures (lab values, imaging, endoscopy)
- Prior treatments: Specific medications, doses, dates, outcomes
- Clinical rationale: Why Cimzia is appropriate vs. alternatives
- Contraindications: Reasons other treatments cannot be used
- Treatment goals: Expected outcomes and monitoring plan
- Guideline support: References to ACR, ACG, or FDA labeling
Key clinical evidence to strengthen your submission:
- Elevated CRP (>3.0 mg/L) or ESR (>28 mm/hr for men, >30 for women)
- Active joint counts or endoscopic findings
- Failed response to preferred agents with documented dates
Appeals Process for Illinois
Internal Appeals Timeline
| Appeal Level | Deadline to File | UnitedHealthcare Response Time | Success Rate |
|---|---|---|---|
| First Level | 180 days from denial | 15 days (72 hours if urgent) | ~85% overturned |
| Second Level | Per plan guidelines | 15 days (72 hours if urgent) | Varies |
External Review (Illinois-Specific)
After exhausting internal appeals, Illinois residents can request external review:
Timeline: Must request within 30 days of final internal denial (stricter than federal 4-month rule)
Process:
- Contact Illinois Department of Insurance at (877) 527-9431
- Submit external review application with all denial documentation
- Independent physician reviewer assigned within 5 business days
- Final decision rendered within 30 days total
- Binding decision - UnitedHealthcare must comply if overturned
Illinois Department of Insurance Resources:
- External review forms and guidance
- Consumer assistance hotline
- Complaint filing for insurance violations
Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to payer requirements.
Common Denial Reasons & Solutions
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| Missing TB/HBV screening | Submit recent test results | Lab reports within 12 months |
| Insufficient step therapy | Document failed trials with dates/doses | Pharmacy records, clinic notes |
| Wrong prescriber type | Specialist consultation or referral | Rheumatology/GI consultation note |
| Combination therapy concern | Confirm no concurrent biologics | Current medication list |
| Not medically necessary | Strengthen clinical evidence | Inflammatory markers, imaging |
From Our Advocates
We've seen UnitedHealthcare approvals improve significantly when providers include specific inflammatory marker values and document exact dates of prior therapy failures. One common pattern: initial denials for "insufficient step therapy" are often overturned when the appeal includes pharmacy fill records showing adequate trial duration and documented intolerance or lack of efficacy.
When to Escalate
Contact Illinois regulators if:
- UnitedHealthcare misses response deadlines
- Denial reasons seem inappropriate or inconsistent
- Pattern of unreasonable denials
Illinois Department of Insurance
- Consumer hotline: (877) 527-9431
- Online complaint portal
- External review coordination
For complex cases requiring extensive clinical documentation and payer-specific appeal strategies, Counterforce Health helps patients and providers build targeted appeals that address specific denial reasons with appropriate evidence and citations.
FAQ
How long does UnitedHealthcare prior authorization take in Illinois? Standard PA requests: 15 days. Urgent requests: 72 hours. Mark requests urgent if treatment delay could harm patient health.
What if Cimzia is non-formulary on my plan? Request formulary exception with medical necessity documentation. External review may be needed if internal appeals fail.
Can I get expedited appeals in Illinois? Yes, for urgent medical situations. UnitedHealthcare must respond within 72 hours for expedited appeals.
Does step therapy apply if I failed treatments outside Illinois? Yes, documented treatment failures from any location count toward step therapy requirements if properly documented.
What happens if I'm denied twice internally? You can request external review through Illinois Department of Insurance within 30 days of final denial.
Are there patient assistance programs for Cimzia? UCB offers CIMplicity copay assistance for commercial insurance. Patient assistance programs available for uninsured patients.
Do I need a specialist to prescribe Cimzia? UnitedHealthcare requires prescription by or consultation with rheumatologist, gastroenterologist, or dermatologist depending on condition.
How much will Cimzia cost with UnitedHealthcare? Specialty tier placement typically means 20-50% coinsurance or $150-500 copay per fill, depending on your specific plan.
Sources & Further Reading
- UnitedHealthcare Cimzia Medical Policy
- UnitedHealthcare Prior Authorization Medical Necessity Form
- Illinois Department of Insurance External Review
- FDA Cimzia Prescribing Information
- UnitedHealthcare Provider Portal
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 verify current requirements with your specific UnitedHealthcare plan and consult healthcare providers for medical decisions. For personalized assistance with appeals and prior authorizations, contact the Illinois Department of Insurance consumer hotline at (877) 527-9431.
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