By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (certolizumab pegol) Covered by Cigna in Pennsylvania: Complete Requirements Checklist

Quick Answer: Getting Cimzia Covered by Cigna in Pennsylvania

Cigna requires prior authorization for Cimzia (certolizumab pegol) in Pennsylvania. Your fastest path to approval: (1) Ensure you have an FDA-approved diagnosis with documented failure of conventional therapy, (2) Complete TB and hepatitis B screening, and (3) Have your specialist submit the Cigna Cimzia prior authorization form with clinical documentation. First step today: Call your rheumatologist or gastroenterologist to confirm they have your complete treatment history and can document prior therapy failures. Pennsylvania residents benefit from a new external review program with a 50% overturn rate if initially denied.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Setup
  8. After Submission: What to Expect
  9. Common Denial Prevention Tips
  10. Appeals Process in Pennsylvania
  11. Cost Assistance Options
  12. Frequently Asked Questions

Who Should Use This Guide

This checklist is designed for Pennsylvania residents with Cigna insurance who need Cimzia (certolizumab pegol) for:

  • Crohn's disease (moderate to severe)
  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Non-radiographic axial spondyloarthritis

Expected outcome: With complete documentation, most Cimzia prior authorizations are approved within 3-5 business days. If denied, Pennsylvania's new external review program overturns approximately 50% of denials when proper evidence is submitted.

Member & Plan Basics

Coverage Requirements at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all indications Cigna formulary
Formulary Tier Specialty tier (typically Tier 4-5) Your plan documents
Step Therapy Must try preferred anti-TNF first Cigna step therapy policy
Quantity Limits Per FDA dosing guidelines Plan-specific
Specialty Pharmacy Usually requires Accredo Cigna member services

Plan Type Considerations

  • Commercial plans: Standard PA requirements apply
  • Medicare Advantage: May have additional step therapy requirements
  • Medicaid managed care: Follow standard Cigna protocols with state oversight

Clinical Criteria Requirements

Diagnosis-Specific Requirements

Crohn's Disease (ICD-10: K50.00–K50.919)

  • Moderate to severe active disease
  • Failed or intolerant to corticosteroids OR conventional therapy (azathioprine, 6-mercaptopurine, methotrexate)
  • Prescribed by or in consultation with gastroenterologist

Rheumatoid Arthritis (ICD-10: M05.XXX, M06.0XX–M06.9XX)

  • Active disease affecting knees, ankles, elbows, wrists, hands, and/or feet
  • Failed at least one conventional DMARD (methotrexate, leflunomide, sulfasalazine)
  • Objective measures required (CRP, ESR, validated activity scores)
  • Rheumatologist prescription required

Psoriatic Arthritis (ICD-10: L40.50–L40.59, M07.0–M07.3)

  • Active joint and/or skin involvement
  • Failed conventional DMARD therapy
  • Rheumatologist consultation required

Ankylosing Spondylitis (ICD-10: M45.0–M45.9)

  • Objective evidence of inflammation (elevated CRP or MRI evidence)
  • Failed conventional therapy
  • Rheumatologist prescription required

Universal Requirements

  • Age: 18 years or older for adult indications
  • TB screening: Negative tuberculin skin test or interferon-gamma release assay
  • Hepatitis B screening: HBsAg, anti-HBs, and anti-HBc results required
  • Dosing: Must follow FDA-approved dosing schedule
  • Contraindications: No concurrent use with other biologics

Coding & Documentation Requirements

Essential Codes

  • ICD-10: Use specific diagnosis codes listed above
  • HCPCS/J-codes: J0717 (certolizumab pegol, 1 mg)
  • NDC: Varies by package size (verify with pharmacy)

Documentation Standards

  • Complete medical history with diagnosis confirmation
  • Detailed prior therapy history with dates, dosages, and reasons for discontinuation
  • Current disease activity assessment
  • Treatment goals and monitoring plan

Documentation Packet Checklist

Provider Requirements

  • Completed Cigna Cimzia prior authorization form
  • Medical necessity letter with clinical rationale
  • Chart notes documenting diagnosis and disease severity
  • Prior therapy documentation (medications tried, duration, outcomes)
  • TB and hepatitis B screening results
  • Current lab results (CRP, ESR if applicable)
  • Specialist consultation notes

Medical Necessity Letter Components

Your provider's letter should include:

  1. Patient demographics and diagnosis with ICD-10 code
  2. Disease severity and current symptoms
  3. Complete prior therapy history with specific reasons for failure/intolerance
  4. Clinical rationale for Cimzia selection
  5. Treatment goals and monitoring plan
  6. Supporting literature (FDA labeling, clinical guidelines)
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements.

Submission Process

Step-by-Step Submission

  1. Gather documentation (allow 1-2 weeks for complete packet)
  2. Complete PA form using most current version
  3. Submit via preferred method:
    • Electronic: CoverMyMeds, ExpressPAth, or Surescripts
    • Fax: Use number on PA form (verify current number)
    • Portal: Cigna provider portal for electronic submission

Required Fields That Commonly Cause Rejections

  • Incomplete patient demographics
  • Missing ICD-10 diagnosis code
  • Unsigned forms
  • Missing TB/hepatitis B screening dates and results
  • Incomplete prior therapy documentation

Specialty Pharmacy Setup

Accredo Enrollment Process

Most Cigna plans require Cimzia to be dispensed through Accredo Specialty Pharmacy.

Transfer Steps:

  1. Verify requirement: Confirm with Cigna that Accredo is mandatory
  2. Contact Accredo: Call 1.877.882.3324 to initiate transfer
  3. Provide information: Insurance details, prescriber info, current pharmacy
  4. Set up delivery: Home or clinic delivery options available
  5. Register online: Create account at accredo.com for tracking

Timeline: Allow 2 weeks before current supply runs out to avoid therapy interruption.

After Submission: What to Expect

Review Timeline

  • Standard review: 3-5 business days with complete documentation
  • Expedited review: 24-72 hours for urgent medical situations
  • Incomplete submissions: Returned within 1-2 days with specific requests

Status Tracking

  • Confirmation number: Record for all submissions
  • Status checks: Call Cigna provider services or check online portal
  • Documentation: Keep copies of all submitted materials

Common Denial Prevention Tips

Five Most Common Pitfalls and Solutions

Denial Reason Prevention Strategy
Missing TB/hepatitis B screening Submit lab results with dates within 6 months of request
Inadequate prior therapy documentation Provide specific dates, dosages, duration, and failure reasons
Step therapy not met Document trial of preferred anti-TNF or request exception with clinical rationale
Non-specialist prescriber Ensure rheumatologist or gastroenterologist signs prescription
Incomplete diagnosis documentation Include disease severity measures and objective findings
Note: Pennsylvania's external review program has overturned 50% of insurance denials in its first year, making appeals particularly worthwhile for Pennsylvania residents.

Appeals Process in Pennsylvania

Internal Appeals (Required First Step)

  • Timeline: 180 days from denial date
  • Process: Submit appeal through Cigna member portal or by mail
  • Documentation: Include all supporting clinical evidence
  • Response time: 30 days for standard, 72 hours for expedited

Pennsylvania External Review (After Internal Appeals)

Pennsylvania launched its Independent External Review Program in January 2024, providing state-supervised appeals with impressive success rates.

Key Details:

  • Eligibility: After receiving Final Adverse Benefit Determination
  • Timeline: 4 months to request external review
  • Success rate: Approximately 50% of denials overturned
  • Process: Submit online at pa.gov or by mail/fax
  • Decision timeline: 45 days standard, 72 hours expedited
  • Cost: No fee to patient

Contact: Pennsylvania Insurance Department Office of Consumer Services (phone number available at pa.gov)

Cost Assistance Options

Manufacturer Support

  • UCB CareConnect: Patient assistance program for eligible uninsured/underinsured patients
  • Copay assistance: May reduce out-of-pocket costs for commercially insured patients
  • Contact: Visit UCB USA website for current programs

Additional Resources

  • Pennsylvania Health Law Project: Free assistance with insurance appeals
  • Pennie marketplace: Consumer hotline for marketplace plan issues
  • Foundation grants: Various organizations provide assistance for autoimmune conditions

Frequently Asked Questions

How long does Cigna prior authorization take in Pennsylvania? Standard reviews take 3-5 business days with complete documentation. Expedited reviews for urgent situations are completed within 24-72 hours.

What if Cimzia is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and lack of suitable alternatives on formulary.

Can I get an expedited appeal if denied? Yes, if your condition poses an imminent threat to health. Your doctor must document the urgent medical need.

Does step therapy apply if I tried anti-TNFs outside Pennsylvania? Yes, documented prior therapy from any location counts toward step therapy requirements if properly documented.

What happens if I pay out-of-pocket during appeals? If your appeal is successful, Cigna must provide retroactive coverage and reimburse out-of-pocket expenses.

How do I transfer from another specialty pharmacy to Accredo? Call Accredo at 1.877.882.3324. They will coordinate the transfer with your current pharmacy and prescriber.

What's the difference between internal and external appeals? Internal appeals are reviewed by your insurance company. External appeals in Pennsylvania are reviewed by independent medical experts through the state program.

Can I get help with my appeal? Yes, Pennsylvania offers free consumer assistance through the Health Law Project and Insurance Department consumer services.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, incorporating the right clinical evidence and procedural details that payers expect.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance requirements and processes may change. Always verify current requirements with your insurance plan and consult with your healthcare provider for medical decisions. For assistance with complex appeals, consider consulting with insurance advocacy services like Counterforce Health that specialize in evidence-based insurance appeals.

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