By Counterforce Health Team in Cimzia (certolizumab pegol) —

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

Answer Box: Getting Cimzia Covered by Cigna in Washington

Cigna requires prior authorization for Cimzia (certolizumab pegol) across all FDA-approved conditions. In Washington, your fastest path to approval involves: (1) Having your specialist submit the PA form with documented failure of conventional therapy and preferred TNF inhibitors, plus required TB/hepatitis B screening results, (2) Using Accredo specialty pharmacy for prescription fulfillment, and (3) If denied, pursuing Washington's robust internal appeal process followed by independent external review through the Office of the Insurance Commissioner. Start today by confirming your plan's specific requirements via the Cigna member portal or calling the number on your insurance card.

Table of Contents

Plan Types & Coverage Implications

Cigna offers HMO, PPO, and EPO plans in Washington, each with different network rules that can affect your Cimzia access:

HMO Plans: Typically require primary care physician referrals for specialists and restrict coverage to in-network providers. For Cimzia, you'll need an in-network rheumatologist or gastroenterologist to manage your care and submit prior authorization requests.

PPO Plans: Offer more flexibility with out-of-network coverage (at higher cost) and no referral requirements. This can be advantageous if your preferred specialist isn't in Cigna's network.

EPO Plans: Combine lower costs with specialist access without referrals, but limit coverage to in-network providers except for emergencies.

All plan types require prior authorization for Cimzia and typically use Accredo as the preferred specialty pharmacy. Check your specific plan documents or call member services to confirm network restrictions and specialty pharmacy requirements.

Formulary Status & Tier Placement

Cimzia is included on the Cigna National Formulary as a specialty medication requiring prior authorization for all FDA-approved indications:

  • Rheumatoid arthritis (moderate to severe)
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Non-radiographic axial spondyloarthritis
  • Plaque psoriasis (moderate to severe)
  • Crohn's disease (moderate to severe)
  • Polyarticular juvenile idiopathic arthritis (ages 2+, as of September 2024)

Tier Placement: Cimzia typically appears on Tier 4 or 5 (specialty tier), with higher cost-sharing than generic medications. Your specific tier placement depends on your individual plan design.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Source
PA Required All indications need approval Cigna Policy CNF_431
Step Therapy Must try preferred TNF inhibitors first Cigna Policy IP_0672
Specialist Required Rheumatologist, gastroenterologist, or dermatologist Cigna PA Forms
TB/Hep B Screening Mandatory before starting therapy FDA Prescribing Information
Quantity Limits Starter pack + maintenance dosing limits Cigna Policy CNF_133

Medical Necessity Criteria

General Requirements (All Indications):

  • FDA-approved diagnosis confirmed by objective findings
  • Age 18+ (2+ for juvenile arthritis)
  • Inadequate response to at least one conventional DMARD (like methotrexate) with 3-month trial
  • Negative tuberculosis screening (QuantiFERON-TB Gold or PPD skin test)
  • Hepatitis B screening (surface antigen and core antibody)
  • No active serious infections or contraindications to immunosuppression

Step Therapy Requirements:

  • RA/Psoriatic Arthritis: Trial of at least one preferred TNF inhibitor (adalimumab products, etanercept)
  • Ankylosing Spondylitis: Trial of two NSAIDs plus preferred TNF inhibitor
  • Plaque Psoriasis: Trial of topical therapies, phototherapy or systemic therapy, plus preferred TNF inhibitor
  • Crohn's Disease: Inadequate response to conventional immunomodulators

Specialty Pharmacy Setup

Cigna requires Cimzia prescriptions to be filled through Accredo, their preferred specialty pharmacy partner.

Enrollment Process

  1. Prescription Routing: Your doctor sends the prescription to Accredo via e-prescribe (NCPDP 4436920), fax (888-302-1028), or phone (866-759-1557)
  2. Patient Contact: An Accredo care advocate calls you within 24-48 hours to complete enrollment and schedule delivery
  3. Account Setup: Create your account at Accredo.com or call 800-803-2523 for assistance
  4. Delivery Coordination: Choose home delivery or another convenient location for your monthly shipments
Tip: Accredo offers clinical support services including injection training, side effect monitoring, and adherence programs at no additional cost.

Step-by-Step: Fastest Path to Approval

1. Confirm Specialist Network Status

Who: You or your clinic
Action: Verify your rheumatologist/gastroenterologist is in-network via Cigna's provider directory
Timeline: Same day

2. Complete Required Screenings

Who: Your specialist
Action: Order TB screening (QuantiFERON-TB Gold or PPD) and hepatitis B panel
Timeline: 1-2 weeks for results

3. Document Prior Therapy Failures

Who: Your clinic
Action: Gather records showing inadequate response to methotrexate and preferred TNF inhibitors
Timeline: 2-3 days

4. Submit Prior Authorization

Who: Your specialist's office
Action: Complete Cigna's Cimzia PA form via CoverMyMeds, fax (855-840-1678), or phone (800-882-4462)
Timeline: 5 business days for standard review

5. Set Up Accredo Account

Who: You
Action: Create account and coordinate delivery while PA is pending
Timeline: 1-2 days

6. Track Decision

Who: You and your clinic
Action: Monitor via myCigna app or call member services
Timeline: Decision within 15 days (72 hours for expedited)

7. Start Treatment or Appeal

Who: You and your specialist
Action: Begin therapy if approved, or file internal appeal if denied
Timeline: Treatment starts within days; appeals within 180 days

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing TB screening Submit negative QuantiFERON or PPD results Lab reports with dates
Inadequate step therapy Provide detailed trial history of preferred agents Claims data, clinic notes, dates/doses
Non-formulary status Request formulary exception with medical necessity Specialist letter explaining why alternatives failed
Quantity exceeded Verify dosing aligns with FDA labeling Prescription with proper dosing schedule
Not medically necessary Submit comprehensive clinical documentation Complete treatment history, response measures

Appeals Process in Washington

Washington state provides strong consumer protections for insurance denials through a two-tiered system.

Internal Appeals with Cigna

Filing Deadline: 180 days from denial notice
Process: Submit written appeal with updated medical records and specialist support
Timeline: 30 days for standard review, 72 hours for expedited
Success Rate: Approximately 35-60% with comprehensive documentation

How to File:

  1. Call Cigna member services to request appeal forms
  2. Submit via member portal or mail to address on denial letter
  3. Include peer-to-peer review request with medical director
  4. Attach all supporting clinical documentation

External Review (Washington-Specific)

If Cigna upholds their denial after internal appeals, Washington law provides access to independent external review.

Filing Deadline: 60 days from final internal denial
Process: Request through Washington's Office of the Insurance Commissioner
Timeline: 20 days for standard review, 72 hours for expedited
Outcome: Binding on Cigna if overturned

Contact Information:

  • Phone: 1-800-562-6900 (Consumer Advocacy)
  • Website: Washington Insurance Commissioner
  • Process: Complete "Request for Review by IRO" form included with final denial letter
Note: Washington's external review process has successfully overturned many specialty drug denials, particularly when comprehensive clinical evidence supports medical necessity.

Cost Considerations

List Price: Approximately $5,999 for a two-syringe maintenance pack (verify current pricing with UCB)

Insurance Coverage: Your out-of-pocket costs depend on your plan's specialty tier cost-sharing, which typically ranges from $50-$500+ per month after deductible.

Financial Assistance:

  • Cimzia Complete Support: UCB's patient assistance program offering copay support and free drug programs
  • Washington State Programs: Apple Health (Medicaid) expansion may cover Cimzia with minimal cost-sharing
  • Foundation Grants: Organizations like the Patient Access Network Foundation offer grants for qualifying patients

Counterforce Health helps patients navigate these complex coverage decisions by analyzing denial letters and crafting targeted appeals that address specific payer requirements. Their platform identifies the exact denial reasons and creates evidence-backed rebuttals aligned with Cigna's own policies, potentially saving months of back-and-forth with insurance companies.

FAQ

Q: How long does Cigna prior authorization take for Cimzia in Washington? A: Standard PA review takes up to 15 days. Expedited review (when health could be jeopardized by delay) takes 72 hours. Call member services to request expedited review if clinically appropriate.

Q: What if Cimzia is non-formulary on my specific plan? A: Request a formulary exception by having your specialist submit clinical documentation showing medical necessity and why formulary alternatives are inappropriate. This process typically takes 72 hours for urgent requests.

Q: Can I use a different specialty pharmacy besides Accredo? A: Cigna typically requires Accredo for specialty medications like Cimzia. Using another pharmacy may result in higher costs or denial of coverage. Verify your plan's specific requirements.

Q: Does step therapy apply if I failed TNF inhibitors outside of Washington? A: Yes, documented failures from any location count toward step therapy requirements. Ensure your new Washington provider has complete records of prior treatments and outcomes.

Q: What happens if I move to Washington with an existing Cimzia prescription? A: Contact Cigna member services immediately to ensure continuity of care. Washington law requires insurers to provide temporary coverage during transition periods while new PA requests are processed.

Q: How do I request a peer-to-peer review? A: Your specialist can request a peer-to-peer discussion with Cigna's medical director by calling the number on your denial letter or through the provider portal. This often resolves complex cases more quickly than written appeals.

This information is for educational purposes only and does not constitute medical advice. Coverage policies and requirements may vary by specific plan. Always consult with your healthcare provider and insurance company for the most current information.

For additional support with insurance appeals and coverage decisions, Counterforce Health provides specialized assistance in turning denials into successful approvals through evidence-based advocacy and payer-specific expertise.

Sources & Further Reading

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