By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (Certolizumab Pegol) Covered by Humana in New Jersey: PA Forms, ICD-10 Codes, and Appeals Guide

Answer Box: Getting Cimzia Covered by Humana in New Jersey

Cimzia (certolizumab pegol) requires prior authorization from Humana across all plan types in New Jersey. The fastest path to approval: submit PA with specific ICD-10 codes (M06.9 for RA, K50.9 for Crohn's), documented step therapy failures, and TB/HBV screening results. If denied, you have 65 days to appeal and access to New Jersey's Independent Health Care Appeals Program (IHCAP) for external review. Start today: Call your prescriber to request PA submission via Humana's provider portal or fax to 502-508-9300.

Table of Contents

  1. Coverage Requirements Overview
  2. ICD-10 Coding for Medical Necessity
  3. HCPCS/J-Code and NDC Requirements
  4. Step-by-Step Prior Authorization Process
  5. Common Denial Reasons and Solutions
  6. Humana Appeals Process in New Jersey
  7. New Jersey External Review Rights
  8. Cost Savings and Patient Support
  9. FAQ

Coverage Requirements Overview

Cimzia (certolizumab pegol) is a PEGylated anti-TNF biologic approved for moderate-to-severe Crohn's disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis. With a U.S. list price of approximately $5,999 for a two-syringe maintenance pack, this specialty medication requires careful navigation of Humana's coverage requirements.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all Humana plans Humana PA Lists
Step Therapy Must try preferred TNF inhibitors first Humana Step Therapy Guide
Medical vs Pharmacy Benefit J0717 (office admin) = Medical; self-admin = Pharmacy HCPCS Guidelines
Screening Requirements TB and Hepatitis B testing mandatory FDA Prescribing Information
Appeal Deadline 65 days from denial notice Humana Member Guide

ICD-10 Coding for Medical Necessity

Accurate ICD-10 coding is critical for Humana prior authorization approval. Your prescriber must document specific diagnosis codes that align with FDA-approved indications.

Rheumatoid Arthritis Codes

  • M06.9: Rheumatoid arthritis, unspecified
  • M06.0xx: Rheumatoid arthritis without rheumatoid factor (specify site)
  • M05.6xx: Rheumatoid arthritis with involvement of other organs

Documentation Requirements: Include rheumatoid factor status, affected joints with laterality, disease activity level (active/remission), and objective findings like elevated CRP or ESR.

Crohn's Disease Codes

  • K50.9: Crohn's disease, unspecified
  • K50.0xx: Crohn's disease of small intestine
  • K50.1xx: Crohn's disease of large intestine with complications

Documentation Requirements: Specify anatomical location, disease behavior (stricturing/penetrating), current symptoms, and endoscopic or imaging findings.

Other Approved Indications

  • Psoriatic Arthritis: L40.52-L40.59 (site-specific)
  • Ankylosing Spondylitis: M45.0-M45.9 (by spinal region)
  • Plaque Psoriasis: L40.0
Clinician Tip: Use the EAT framework—Evaluate current status, Address progression with objective measures, and document Treatment response to previous therapies. This supports both accurate coding and medical necessity.

HCPCS/J-Code and NDC Requirements

Cimzia billing varies by administration setting, affecting which Humana benefit applies.

Medical Benefit (Part B) - Office Administration

  • HCPCS Code: J0717 (Injection, certolizumab pegol, 1 mg)
  • NDC Examples: 50474-0710-81 or 50474-0700-62
  • CPT Codes: 96372 (IM injection) or 96401 (subcutaneous administration)
  • Medicare Payment: $3.913 per unit; patient coinsurance 20% ($0.783/unit)

Pharmacy Benefit (Part D) - Self-Administration

Self-administered Cimzia falls under Part D pharmacy benefits with specialty tier copays.

Billing Requirements

All Humana claims for J0717 must include:

  • Patient demographics and member ID
  • Corresponding NDC number
  • Accurate unit calculations (1 mg = 1 unit)
  • Appropriate diagnosis codes

Step-by-Step Prior Authorization Process

Step 1: Gather Required Documentation

Who: Prescriber's office Timeline: 1-2 business days

Collect:

  • Complete medical history with diagnosis codes
  • Documentation of previous TNF inhibitor trials and outcomes
  • TB screening (chest X-ray, interferon-gamma release assay)
  • Hepatitis B panel (HBsAg, anti-HBs, anti-HBc)
  • Current symptoms and disease activity measures

Step 2: Submit Prior Authorization Request

Who: Prescriber or authorized staff How:

Timeline: Standard review 72 hours; expedited 24 hours if medically urgent

Step 3: Include Medical Necessity Letter

Your prescriber should address:

  • Specific diagnosis with severity documentation
  • Previous treatment failures with dates and reasons
  • Why Cimzia is medically necessary vs. formulary alternatives
  • Planned monitoring and treatment goals

Step 4: Track Decision

Humana will notify the prescriber and patient of the determination. If approved, confirm pharmacy benefits and copay assistance eligibility.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing Step Therapy Document trials of preferred TNF inhibitors Treatment dates, dosing, duration, reason for discontinuation
Inadequate Screening Complete TB/HBV testing Recent chest X-ray, IGRA results, hepatitis B panel
Non-Specific Diagnosis Use precise ICD-10 codes Disease activity measures, joint involvement, complications
Quantity Limits Exceeded Request exception with clinical rationale Weight-based dosing calculations, treatment response data
From Our Advocates: We've seen cases where initial denials were overturned simply by resubmitting with complete TB screening results. Many prescribers forget that both chest imaging AND blood tests are required—having both ready prevents unnecessary delays.

Humana Appeals Process in New Jersey

If your Cimzia prior authorization is denied, you have multiple appeal levels available.

Internal Appeal (Redetermination)

  • Deadline: 65 days from denial notice
  • Timeline: 7 calendar days for Part D decisions
  • How to File: Use Humana's appeal form or written request
  • Include: New medical evidence, peer-reviewed studies supporting Cimzia use, updated clinical notes

Expedited Appeal

Available if standard timeline would jeopardize your health. Requires prescriber statement supporting urgency.

  • Timeline: 24-72 hours
  • Criteria: Serious harm likely if treatment delayed

Independent Review Entity (IRE)

If Humana upholds the denial, you can request external review through Medicare's contracted IRE at no cost.

Organizations like Counterforce Health specialize in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to craft point-by-point rebuttals aligned with payer requirements.

New Jersey External Review Rights

New Jersey residents have additional protection through the Independent Health Care Appeals Program (IHCAP).

When IHCAP Applies

  • After completing Humana's internal appeal process
  • For medical necessity denials
  • Within 180 days of final internal denial

How to File

  1. Contact: Submit directly to Maximus Federal Services (contracted by New Jersey DOBI)
  2. Timeline: 5 business days for preliminary review; 45 days for final decision
  3. Cost: Free to patients (insurers pay all fees)
  4. Decision: Binding on Humana if overturned

IHCAP Contact Information

Note: External review success rates vary, but approximately half of appeals nationwide favor consumers when reviewed by independent medical experts.

Cost Savings and Patient Support

Manufacturer Support

UCB offers the Cimzia Complete Support Program with:

  • Copay assistance (eligible patients may pay as little as $5 per month)
  • Prior authorization support
  • Injection training and supplies

Foundation Assistance

  • Patient Access Network Foundation: Provides grants for specialty medications
  • Good Days: Offers copay assistance for chronic conditions
  • HealthWell Foundation: Income-based medication grants

State Resources

New Jersey residents may qualify for additional assistance through:

  • NJ FamilyCare (Medicaid expansion)
  • Pharmaceutical Assistance to the Aged and Disabled (PAAD)

FAQ

How long does Humana prior authorization take for Cimzia in New Jersey? Standard PA decisions take 72 hours. Expedited reviews (for urgent medical need) are completed within 24 hours with prescriber support.

What if Cimzia is non-formulary on my Humana plan? Request a formulary exception using Humana's coverage determination form. Your prescriber must document why all formulary TNF inhibitors are ineffective or cause adverse effects.

Can I request an expedited appeal if Humana denies Cimzia? Yes, if the standard appeal timeline would jeopardize your health. Your prescriber must provide a statement supporting the urgency of treatment.

Does step therapy apply if I previously failed TNF inhibitors outside New Jersey? Previous treatment failures should count regardless of location. Ensure your prescriber documents the complete treatment history with dates and reasons for discontinuation.

What happens if both Humana and New Jersey IHCAP deny coverage? For Medicare Advantage plans, you can pursue additional federal appeal levels. For other plans, consult with a healthcare attorney or patient advocate about additional options.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-backed appeals. Their platform identifies denial basis—whether PA criteria, step therapy, or medical necessity—and develops targeted rebuttals using FDA labeling, peer-reviewed studies, and payer-specific workflows to improve approval rates.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For official New Jersey insurance regulations and consumer assistance, visit the NJ Department of Banking and Insurance.

Sources & Further Reading

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