By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (Certolizumab Pegol) Covered by Blue Cross Blue Shield in Georgia: Complete PA Guide with Forms and Appeals

Answer Box: Getting Cimzia Covered by Blue Cross Blue Shield in Georgia

Cimzia (certolizumab pegol) requires prior authorization from Blue Cross Blue Shield of Georgia (Anthem) for all commercial plans. To get coverage, you need documented failure of step-therapy requirements (typically other TNF inhibitors like Humira), proper diagnosis codes, and TB/hepatitis screening. Submit PA requests through the Availity provider portal or member portal at bcbsga.com. First step today: Call the member services number on your ID card to confirm your plan's specific formulary tier and step-therapy requirements for Cimzia.

Table of Contents

Start Here: Verify Your Plan Coverage

Before starting the prior authorization process, confirm your specific Blue Cross Blue Shield plan details:

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all commercial plans Member portal or ID card Anthem Provider News
Formulary Tier Specialty tier (high copay) bcbsga.com formulary search Member portal
Step Therapy Must try preferred TNF inhibitors first Policy CRX-ALL-0675-21 Anthem Policy PDF
Age Requirement 18+ years old Same policy document Anthem Policy PDF
TB/HBV Screening Required before approval Clinical documentation Anthem Policy PDF

Action Step: Log into your member portal at bcbsga.com and search for "Cimzia" in the formulary tool to see your specific plan's requirements.

Required Forms and Documentation

Prior Authorization Requirements

Blue Cross Blue Shield of Georgia requires comprehensive documentation for Cimzia approval. Based on Anthem's policy CRX-ALL-0675-21, you'll need:

Clinical Documentation Checklist:

  • Confirmed diagnosis with ICD-10 codes (moderate-to-severe disease)
  • Documentation of failed conventional therapies
  • For most indications: trial/failure of preferred biologic (Humira, Avsola/infliximab)
  • TB skin test (TST) or CDC-equivalent screening results
  • Current disease severity assessment
  • Treatment goals and expected outcomes

Indication-Specific Requirements

Crohn's Disease:

  • Plus trial/failure of 1 preferred biologic, unless stable on Cimzia or pregnant/planning pregnancy

Rheumatoid Arthritis:

  • After failure of nonbiologic DMARDs (methotrexate, sulfasalazine)

Psoriatic Arthritis:

  • After nonbiologic DMARDs; trial of preferred biologic unless exceptions apply

Plaque Psoriasis:

  • After conventional therapy and 1 preferred biologic (Otezla) unless exceptions
3% body surface area involvement or disabling symptoms
Clinician Corner: The medical necessity letter should specifically address why step-therapy requirements cannot be met. Common acceptable reasons include contraindications, previous intolerance, drug interactions, or pregnancy (for certain indications where Cimzia has pregnancy data).

Submission Portals and Methods

Availity Essentials Portal:

  • Navigate to Patient Registration > Authorization app
  • Upload all required documentation
  • Track approval status in real-time
  • Access at Availity.com

Member Portal:

  • Log in at bcbsga.com
  • Navigate to "Pharmacy" or "Prior Authorization" section
  • Upload prescriber letter and supporting documents

Alternative Submission Methods

Fax Submission:

  • Check your denial letter or call member services for current fax number
  • Include cover sheet with member ID and prescriber information
  • Keep fax confirmation receipt

Mail Submission:

  • Address varies by plan type (commercial, SHBP, FEP)
  • Use certified mail for tracking
  • Include all documentation in organized packet

Specialty Pharmacy Onboarding

Cimzia requires specialty pharmacy dispensing through Blue Cross Blue Shield's network. Here's the onboarding process:

Step-by-Step Onboarding

  1. Insurance Verification
    • Specialty pharmacy confirms BCBS eligibility and PA status
    • Verify copay and manufacturer assistance eligibility
  2. Clinical Intake
    • Complete health questionnaire (phone or online)
    • Review injection technique and storage requirements
    • Discuss side effects and monitoring needs
  3. Delivery Setup
    • Schedule home delivery or provider office shipment
    • Arrange refrigerated shipping with tracking
    • Confirm signature requirements
  4. Ongoing Support
    • Refill reminders and adherence monitoring
    • Clinical check-ins for side effects
    • Lab monitoring coordination

Transfer Instructions: If your prescription is currently at another pharmacy, contact the Blue Cross Blue Shield designated specialty pharmacy to initiate a transfer. Provide your member ID, prescriber information, and current pharmacy details.

Support Lines and Contacts

Primary Contact Numbers

Member Services:

  • Use the number on your ID card for plan-specific support
  • General Anthem Georgia: 1-800-331-1476 (TTY 711)
  • Hours: Monday-Friday, 8 AM-5 PM ET

State Health Benefit Plan (SHBP) Members:

  • Member Services: 1-855-641-4862 (TTY 711)
  • Hours: Monday-Friday, 8 AM-8 PM ET

Federal Employee Program (FEP) Members:

  • Customer Service: 1-800-282-2473
  • National Information Center: 1-800-411-BLUE (2583)

What to Ask When You Call

For Coverage Questions:

  • "Is Cimzia covered under my pharmacy benefit?"
  • "What are the step-therapy requirements for my plan?"
  • "Which specialty pharmacy should I use?"

For Prior Authorization Status:

  • "What's the status of my Cimzia PA request?"
  • "What additional documentation is needed?"
  • "Can this be expedited for urgent medical need?"

Appeals Process for Georgia Members

If your Cimzia prior authorization is denied, Georgia law provides a structured appeals process.

Internal Appeals Process

Timeline: Within 180 days of denial for commercial plans

How to Submit:

  • Member portal at bcbsga.com
  • Call member services number on ID card
  • Mail written appeal to address on denial letter

Required Documents:

  • Original denial letter
  • Additional clinical documentation
  • Provider letter addressing denial reasons
  • Failed therapy documentation

External Review (Georgia Department of Insurance)

Timeline: Within 60 days of final internal denial

Process:

  1. Obtain Georgia external review application form
  2. Submit to Georgia Office of Commissioner of Insurance
  3. Include all supporting medical documentation
  4. Independent review organization makes binding decision

Contact Information:

  • Phone: 1-800-656-2298
  • Address: Office of Commissioner of Insurance and Safety Fire, Consumer Services Division, 2 Martin Luther King Jr. Dr., West Tower, Suite 702, Atlanta, GA 30334
From Our Advocates: We've seen successful appeals when providers clearly document why preferred alternatives failed or caused intolerable side effects. One case involved a patient with rheumatoid arthritis who had severe injection site reactions to adalimumab - the detailed documentation of this adverse event, combined with photos and clinical notes, led to Cimzia approval on internal appeal.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Missing TB/HBV screening Submit screening results TST or IGRA results, hepatitis panel
Step therapy not met Document failed trials Prescription records, clinical notes on failures
Lack of diagnosis severity Provide disease activity scores CDAI, DAS28, PASI scores as appropriate
Missing medical necessity Strengthen provider letter Detailed clinical rationale, guideline references
Quantity limits exceeded Justify dosing rationale FDA labeling, clinical studies supporting dose

Cost Savings and Financial Assistance

Manufacturer Support Programs

UCB CareConnect:

  • Copay assistance for eligible patients
  • May reduce out-of-pocket costs to $5-$10 per month
  • Income and insurance restrictions apply
  • Apply at UCB's official website or ask specialty pharmacy

Foundation Grants

Patient Advocate Foundation:

  • Provides grants for medication costs
  • Income-based eligibility
  • Apply online with financial documentation

HealthWell Foundation:

  • Disease-specific grant programs
  • Covers copays and deductibles
  • First-come, first-served basis

Counterforce Health helps patients navigate these coverage challenges by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals that address specific payer requirements.

Frequently Asked Questions

How long does Blue Cross Blue Shield PA take in Georgia? Standard prior authorizations take 3-15 business days. Urgent requests are processed within 24-72 hours if delay could harm your health.

What if Cimzia is non-formulary on my plan? You can request a formulary exception with strong clinical justification. Document why formulary alternatives are inappropriate or contraindicated.

Can I request an expedited appeal? Yes, if your medical condition is urgent. Your provider must document that delay poses serious risk to your health or ability to regain function.

Does step therapy apply if I failed medications outside Georgia? Yes, documented failures from other states count toward step-therapy requirements. Provide prescription records and clinical notes from previous providers.

What happens if external review denies my appeal? The external review decision is binding on the insurer. Further disputes would require legal action, though this is rare.

How do I transfer from another specialty pharmacy? Contact your Blue Cross Blue Shield designated specialty pharmacy with your member ID, prescriber information, and current pharmacy details. They'll initiate the transfer process.

Can I use manufacturer copay cards with Blue Cross Blue Shield? This varies by plan. Some allow manufacturer assistance, while others (particularly government plans) prohibit it. Check with member services.

What if I'm pregnant and need Cimzia? Pregnancy may qualify as an exception to step-therapy requirements for certain indications. Cimzia has pregnancy safety data that other TNF inhibitors lack.

For complex coverage challenges, Counterforce Health specializes in helping patients and clinicians get prescription drugs approved by creating targeted appeals that address specific payer requirements and leverage appropriate clinical evidence.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult healthcare providers for medical decisions. For assistance with complex appeals, consider consulting with patient advocacy organizations or legal professionals specializing in insurance matters.

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