By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (Certolizumab Pegol) Covered by Cigna in Texas: Complete PA Guide & Appeal Process

Answer Box: Getting Cimzia Covered by Cigna in Texas

Cigna requires prior authorization for Cimzia (certolizumab pegol) with 6-month initial approvals and 1-year renewals. Most patients need to try preferred TNF inhibitors first (adalimumab biosimilars, Enbrel) unless medically contraindicated. Your fastest path: Have your rheumatologist/gastroenterologist submit the Cigna PA form with TB/hepatitis B screening results, prior therapy documentation, and objective inflammation markers. Start 30-60 days before you need the medication. If denied, Texas law provides strong appeal rights through both internal Cigna reviews and external Texas Department of Insurance review.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Step Therapy Requirements
  4. Medical Necessity Criteria
  5. Specialty Pharmacy Requirements
  6. Costs and Financial Assistance
  7. Appeals Process in Texas
  8. Renewal and Reauthorization
  9. Common Denial Reasons
  10. Frequently Asked Questions

Coverage Basics

Is Cimzia covered by Cigna? Yes, but with restrictions. Cimzia (certolizumab pegol) is a specialty medication that requires prior authorization across all Cigna plans in Texas. It's typically placed on higher formulary tiers due to its cost—around $6,000 for a maintenance dose—and the availability of preferred alternatives.

Which Cigna plans cover Cimzia? All major Cigna health plans include Cimzia on their formularies, including:

  • Commercial employer plans
  • Individual marketplace plans
  • Medicare Advantage plans (through Express Scripts)

The specific requirements may vary slightly between plan types, but the core prior authorization criteria remain consistent.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm specialist involvement - Cigna requires prescribing by or consultation with a specialist (rheumatologist for RA/PsA, gastroenterologist for Crohn's, dermatologist for psoriasis)
  2. Complete required screenings - Order tuberculosis testing (PPD ≥5mm or IGRA), hepatitis B serology, and chest X-ray before submission
  3. Download and complete the PA form - Use the official Cigna Cimzia PA form
  4. Submit via preferred method - E-prescribe through CoverMyMeds, SureScripts, or the Cigna provider portal
  5. Include all documentation - Medical records, lab results, prior therapy records, and prescription receipts
  6. Follow up within 72 hours - Standard reviews take 5 business days; urgent cases can be expedited by calling (800) 882-4462
  7. Prepare for potential peer-to-peer - Many approvals happen during physician-to-physician discussions before formal denial
Tip: Start the PA process 30-60 days before your patient needs the medication. Specialty drug approvals often require additional documentation rounds.

Step Therapy Requirements

Cigna typically requires patients to try preferred TNF inhibitors before approving Cimzia. The specific requirements include:

Preferred First-Line Options (try 2 of these):

  • Adalimumab biosimilars: Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry
  • Etanercept (Enbrel)
  • Other targeted therapies: Rinvoq, Taltz, Xeljanz/XR, Cosentyx, Otezla, Skyrizi

Step Therapy Exceptions:

  • Medical contraindication to preferred agents
  • Previous intolerance or adverse reaction
  • Drug interaction with current medications
  • Documented failure on preferred therapy outside current plan

Documentation Required for Exceptions:

  • Pharmacy claims showing 90+ days of preferred therapy
  • Medical records documenting adverse effects
  • Prescriber attestation of medical necessity

When requesting a step therapy exception, be specific about why preferred alternatives aren't appropriate. Counterforce Health helps clinicians build evidence-backed appeals when standard step therapy doesn't fit the patient's clinical picture.

Medical Necessity Criteria

Required Clinical Documentation

For All Indications:

  • Confirmed diagnosis with appropriate ICD-10 codes
  • Objective evidence of inflammation (elevated CRP/ESR, imaging, endoscopy findings)
  • Specialist evaluation or consultation
  • Negative TB and hepatitis B screening

Condition-Specific Requirements:

Condition Additional Criteria
Rheumatoid Arthritis ≥6 swollen joints; inadequate response to MTX + ≥1 conventional DMARD
Crohn's Disease Objective inflammation; failure of conventional therapy
Psoriatic Arthritis Rheumatologist or dermatologist involvement
Ankylosing Spondylitis HLA-B27 testing; imaging evidence

Clinician Corner: Medical Necessity Letter Checklist

When writing your letter of medical necessity, include:

✓ Patient's condition and severity - Use objective measures (DAS28, CDAI, PASI scores)
✓ Prior treatments attempted - Specific medications, doses, duration, and outcomes
✓ Why alternatives aren't suitable - Contraindications, intolerances, or failures
✓ Expected benefits - Treatment goals and monitoring plan
✓ Supporting guidelines - Reference FDA labeling and specialty society recommendations

Specialty Pharmacy Requirements

Cigna directs Cimzia prescriptions to Accredo, their preferred specialty pharmacy. This isn't optional for most plans—it's required for coverage.

Transfer Process to Accredo

New Prescriptions:

  • E-prescribe directly to Accredo (NCPDP 1620 Century Center Pkwy, Memphis, TN 38134-8822)
  • Include Accredo as the preferred pharmacy on your PA form

Transferring Existing Prescriptions:

  • Call Accredo at 877-826-7657 (Mon-Fri 7am-10pm CST, Sat 7am-4pm CST)
  • Have your prescription number and insurance information ready
  • Online transfers available at Accredo.com after first fill

Delivery Options:

  • Free home delivery with refrigerated handling
  • Delivery to physician office if preferred
  • Includes injection supplies and sharps containers
Note: Some Cigna plans allow 1-2 retail fills before requiring specialty pharmacy transfer. Check your specific plan documents or call member services.

Costs and Financial Assistance

Understanding Your Costs

Cimzia costs vary significantly based on your Cigna plan design:

  • Tier 4 Specialty plans: Typically 25-40% coinsurance
  • HMO plans: May have fixed copays ($50-200 per month)
  • High-deductible plans: Full cost until deductible met

Financial Assistance Options

Manufacturer Support:

  • Check UCB's patient assistance programs at Cimzia.com
  • Income-based eligibility for uninsured or underinsured patients

Accredo Support:

  • Patient advocates help navigate coverage issues
  • Assistance with PA appeals and side effect management

State and National Programs:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Texas specialty drug assistance programs

For comprehensive help navigating both coverage and cost issues, Counterforce Health specializes in turning insurance denials into successful appeals while connecting patients with appropriate financial resources.

Appeals Process in Texas

Texas provides robust patient protection for insurance appeals, including specialty drug denials.

Internal Appeal with Cigna

Timeline: File within 180 calendar days of denial
Decision: 30 days for medical necessity appeals, 72 hours for expedited
How to File: MyCigna.com portal, mail, or fax (address on denial letter)

Required Documents:

  • Original denial notice
  • Medical records supporting necessity
  • Peer-to-peer discussion notes (if conducted)
  • Additional clinical evidence

External Review through Texas Department of Insurance

If Cigna denies your internal appeal, Texas law provides independent external review:

Timeline: File within 4-6 months of final internal denial
Decision: 60 days standard, 72 hours expedited
Cost: Free to patients (insurer pays)
Success Rate: Approximately 40% of external reviews overturn denials

How to File:

  • Online at tdi.texas.gov
  • Include all internal appeal documentation
  • Request expedited review for urgent cases

Texas-Specific Resources

Texas Department of Insurance Consumer Help: 1-800-252-3439
Office of Public Insurance Counsel: 1-877-611-6742
TDI IRO Information Line: 1-866-554-4926

From our advocates: We've seen many Cimzia denials overturned when patients provide objective inflammation markers and document specific failures of preferred alternatives. The key is building a point-by-point response to the plan's denial reasons using their own policy language.

Renewal and Reauthorization

Authorization Timelines

  • Initial approval: 6 months
  • Continuation approval: 12 months (1 year)
  • No grace period: Coverage stops immediately when authorization expires

Renewal Requirements

Start Early: Begin renewal process 60-90 days before expiration

Required Documentation:

  • Clinical progress notes from last 2-3 visits
  • Evidence of positive response or disease stability
  • Recent lab results (if clinically indicated)
  • Adherence documentation from pharmacy

Ongoing Approval Criteria:

  • Patient established on Cimzia for ≥3 months
  • No disease progression or safety concerns
  • Continued medical necessity per specialist

Common Denial Reasons

Denial Reason How to Overturn
Missing TB screening Submit PPD/IGRA results, chest X-ray, risk questionnaire
Step therapy not met Document preferred therapy failure with pharmacy claims
Lack of specialist involvement Obtain consultation note or transfer care
Insufficient inflammation markers Provide lab results (CRP, ESR), imaging, or endoscopy
Non-formulary status Request formulary exception with clinical justification
Quantity limits exceeded Submit dosing rationale based on weight/severity

Frequently Asked Questions

How long does Cigna PA take in Texas? Standard reviews take 5 business days. Urgent cases are decided within 72 hours if you call (800) 882-4462 to request expedited review.

What if Cimzia is non-formulary on my plan? Request a formulary exception by demonstrating medical necessity. Include documentation of why formulary alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if delays would jeopardize your health. Texas allows concurrent expedited internal and external reviews for urgent cases.

Does step therapy apply if I've failed similar drugs outside Texas? Yes, but you'll need documentation. Pharmacy claims, medical records, or prescriber attestation of prior failures can satisfy step therapy requirements.

What happens if my appeal is denied? You have the right to external review through the Texas Department of Insurance. This independent review is free and has about a 40% success rate.

Why was my prescription transferred to Accredo? Cigna requires specialty medications like Cimzia to be dispensed through their preferred specialty pharmacy for coverage. This ensures proper handling and patient support services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may vary by specific plan and can change over time. Always verify current requirements with Cigna and consult with your healthcare provider regarding treatment decisions. For assistance with complex coverage issues, consider working with patient advocacy services that specialize in insurance appeals.

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