By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (Certolizumab Pegol) Covered by Aetna CVS Health in California: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Cimzia Approved by Aetna CVS Health in California

Cimzia (certolizumab pegol) requires prior authorization from Aetna CVS Health and faces step therapy requirements favoring preferred biologics. Success requires documenting failed trials of preferred TNF inhibitors (like Humira or infliximab biosimilars), negative TB/hepatitis B screening, and meeting diagnosis-specific criteria. If denied, California's Independent Medical Review (IMR) overturns 55-73% of specialty drug denials. First step today: Call Aetna at 1-866-752-7021 to confirm PA requirements and submit complete documentation including TB screening results.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Medical Necessity Letter Essentials
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Process in California
  6. Working with Your Doctor
  7. Cost Savings & Support Programs
  8. When to Escalate to California Regulators
  9. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Aetna Precert List Aetna 2024
TB Screening PPD/IGRA + chest X-ray within 6 months Patient medical records FDA Label
Step Therapy Must try preferred biologics first Aetna Formulary Guidelines Aetna Policy
Diagnosis Codes ICD-10 required (e.g., M05.79 for RA) Provider documentation Clinical requirement
Site of Care Specialty pharmacy (CVS Specialty) CVS Caremark network Plan requirement

Step-by-Step: Fastest Path to Approval

1. Verify Coverage & Requirements

Who: Patient or clinic staff
Action: Call Aetna at 1-866-752-7021 or check the provider portal
Timeline: Same day
Document needed: Member ID, diagnosis, prescriber NPI

2. Complete TB and Hepatitis B Screening

Who: Prescribing physician
Action: Order PPD/IGRA, chest X-ray, hepatitis B panel
Timeline: Results within 1-2 weeks
Requirements: Negative results within 6 months per FDA guidelines

3. Document Prior Therapy Failures

Who: Physician
Action: Gather records of failed trials with preferred agents (Humira, infliximab biosimilars, etanercept)
Timeline: 1-3 days to compile
Requirements: Dates, doses, duration, reason for discontinuation

4. Submit Prior Authorization Request

Who: Physician or clinic staff
Action: Complete Aetna PA form with all documentation
Timeline: Submit within 5 business days
Method: Fax, portal, or CVS Specialty at 1-800-238-7828

5. Request Peer-to-Peer Review (if needed)

Who: Physician
Action: Call Aetna to schedule clinical discussion
Timeline: Within 3-5 days of initial review
Preparation: Have clinical rationale and guidelines ready

6. Monitor Decision Timeline

Who: Patient and clinic
Action: Follow up every 3-5 business days
Timeline: Standard decisions in 30-45 days; expedited in 72 hours
Contact: Aetna customer service on member ID card

7. Appeal if Denied

Who: Patient with physician support
Action: File internal appeal within 180 days
Timeline: 30-day internal review
Next step: California IMR if upheld

Medical Necessity Letter Essentials

Your physician's medical necessity letter is crucial for approval. Here's what Aetna requires based on their clinical policy:

Required Clinical Elements

  • Diagnosis with ICD-10 code (e.g., K50.919 for Crohn's disease, M05.79 for rheumatoid arthritis)
  • Disease severity documentation (CDAI >220 for Crohn's, DAS28 >5.1 for RA)
  • Prior therapy history with specific dates, doses, and failure reasons
  • TB/hepatitis B screening results with dates
  • Contraindications to preferred agents if applicable
  • Treatment goals and expected outcomes

Template Structure

Patient: [Name], DOB: [Date], Member ID: [Number]
Diagnosis: [Condition] (ICD-10: [Code])

Clinical Rationale:
This patient has [moderate-to-severe condition] with inadequate response to conventional therapy including [list specific medications, dates, outcomes]. TB screening completed [date] with negative results. Patient meets FDA indication for Cimzia and Aetna's medical necessity criteria.

Prior Treatments:
- [Medication 1]: [Dose], [Duration], [Outcome/Reason for discontinuation]
- [Medication 2]: [Dose], [Duration], [Outcome/Reason for discontinuation]

Request: Authorization for Cimzia 400mg loading doses (weeks 0, 2, 4) followed by 200mg every 2 weeks maintenance dosing.
From our advocates: We've seen the strongest approvals when physicians include specific quotes from Aetna's own policy criteria in their letters. This shows the insurer that their own guidelines support the request, making denial much harder to justify.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Missing TB screening" Submit recent results PPD/IGRA + chest X-ray within 6 months
"Step therapy not met" Document preferred agent failures Pharmacy records, clinic notes with dates/outcomes
"Not medically necessary" Provide clinical evidence Disease activity scores, functional assessments
"Experimental/investigational" Cite FDA approval FDA label for your indication
"Quantity limits exceeded" Justify dosing Clinical guidelines supporting proposed regimen

Appeals Process in California

California offers some of the strongest patient protections in the nation for specialty drug denials. If Aetna denies your Cimzia request, you have multiple levels of appeal.

Internal Appeal (First Step)

  • Deadline: 180 days from denial
  • Timeline: 30 days for standard review; 72 hours for urgent
  • How to file: Call 1-866-235-5660 or submit via Aetna appeals portal
  • Required: Original denial letter, medical records, physician statement

California Independent Medical Review (IMR)

If Aetna upholds the denial, California's IMR process offers excellent success rates for specialty drugs.

Success rates: 55-73% of specialty drug denials are overturned, with rare disease treatments seeing even higher success rates around 68%.

How to file:

  1. Call DMHC Help Center at 888-466-2219
  2. Submit application at HealthHelp.ca.gov
  3. Include all medical records and denial correspondence

Timeline:

  • Standard IMR: 45 days
  • Expedited IMR: 7 days or less for urgent cases
  • No cost to patients

What happens: Independent California-licensed physicians review your case and make a binding decision. If they overturn the denial, Aetna must authorize coverage.

At Counterforce Health, we specialize in turning insurance denials into successful appeals by analyzing denial letters, identifying the specific coverage criteria that weren't met, and crafting targeted rebuttals with the right clinical evidence. Our platform helps patients and providers build stronger cases that address payers' exact requirements.

Working with Your Doctor

Before Your Appointment

  • Compile symptom timeline: When did symptoms start? How have they progressed?
  • List all treatments tried: Include over-the-counter medications, prescription drugs, and their outcomes
  • Document functional impact: How does your condition affect daily activities, work, relationships?
  • Gather insurance information: Bring your member ID card and any prior denial letters

During Your Visit

  • Be specific about failures: "Humira helped initially but stopped working after 8 months" is more useful than "Humira didn't work"
  • Discuss side effects in detail: Document any adverse reactions that led to discontinuation
  • Ask about peer-to-peer review: Your doctor can request a direct conversation with Aetna's medical reviewer
  • Request copies: Get copies of all lab results, imaging, and clinic notes

After Your Visit

  • Save everything: Keep copies of all documentation in a dedicated folder
  • Follow up proactively: Check on PA status every 3-5 business days
  • Use patient portals: Message your doctor's office through secure portals for updates

Cost Savings & Support Programs

Even with insurance approval, Cimzia can be expensive. Here are ways to reduce your costs:

UCB Patient Support

  • CIMplicity Program: Provides financial assistance and care coordination
  • Copay savings: May reduce out-of-pocket costs to as low as $5 per month
  • Contact: 1-866-424-6942 or UCB Patient Support

Foundation Grants

  • Patient Advocate Foundation: Provides copay assistance for qualifying patients
  • Good Days: Offers financial assistance for chronic disease medications
  • Eligibility: Typically based on income and insurance status

State Programs

California residents may qualify for additional assistance through Medi-Cal or Covered California subsidies.

When to Escalate to California Regulators

If Aetna is not following proper procedures or timelines, you can file a complaint with California's insurance regulators:

Department of Managed Health Care (DMHC)

  • For: HMO and most managed care plans
  • Contact: 888-466-2219
  • Website: DMHC Help Center
  • When to call: Plan not responding to appeals, missing deadlines, or procedural violations

California Department of Insurance (CDI)

  • For: PPO and indemnity plans
  • Contact: 800-927-4357
  • When to file: Similar issues with CDI-regulated plans

Both agencies can intervene on your behalf and ensure Aetna follows California law.

FAQ

How long does Aetna CVS Health prior authorization take in California? Standard PA decisions take 30-45 days. Expedited reviews for urgent cases are completed within 72 hours. You can check status by calling the number on your member ID card.

What if Cimzia is not on my Aetna formulary? You can request a formulary exception with supporting clinical documentation. If denied, this decision can be appealed through California's IMR process with good success rates.

Can I get an expedited appeal in California? Yes, if your doctor certifies that delays could seriously jeopardize your health. Expedited internal appeals are decided within 72 hours, and expedited IMRs within 7 days.

Does step therapy apply if I tried preferred drugs outside California? Yes, prior therapy from any state counts toward step therapy requirements. Make sure your new California doctor has complete records from your previous providers.

What counts as "medical necessity" for Cimzia? Aetna considers Cimzia medically necessary when you have an FDA-approved indication, have tried preferred alternatives, and have appropriate screening completed. Their clinical policy outlines specific criteria.

How much does California IMR cost? Nothing. California law prohibits charging patients for independent medical reviews. The insurance company pays all costs.

Can I switch to CVS Specialty pharmacy after approval? Most Aetna plans require specialty medications like Cimzia to be dispensed through CVS Specialty. Your doctor will coordinate this transition after approval.

What if I'm denied multiple times? Each level of appeal (internal, IMR) is reviewed by different people. Many denials are overturned at higher levels, especially with complete documentation and Counterforce Health's targeted appeal strategies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for the most current requirements and procedures. For additional help with insurance appeals in California, contact the DMHC Help Center at 888-466-2219 or visit HealthHelp.ca.gov.

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