By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (Certolizumab Pegol) Covered by Humana in Texas: Prior Authorization, Step Therapy & Appeals Guide

Quick Answer: Getting Cimzia Covered by Humana in Texas

Cimzia (certolizumab pegol) requires prior authorization from Humana and is subject to step therapy requirements. Your fastest path to approval: 1) Have your doctor document failed trials of preferred anti-TNF biosimilars, 2) Submit a medical necessity letter with your PA request through Humana's provider portal, 3) If denied, file an internal appeal within 65 days. Texas residents have strong external review rights through independent review organizations if internal appeals fail.

Start today: Ask your prescriber to check Humana's current formulary and begin gathering documentation of prior treatment failures.

Table of Contents

Humana Plan Types & Coverage Implications

Humana offers several plan types in Texas, each with different coverage rules for Cimzia:

Medicare Advantage (MA): Most common Humana plan type in Texas. Cimzia coverage follows Medicare Part B (if administered in-office) or Part D (self-administered) rules with Humana-specific formulary restrictions.

Medicare Part D: Standalone prescription drug coverage. Cimzia typically requires prior authorization and step therapy for most Humana Part D plans.

Medicaid (where applicable): Limited Humana Medicaid presence in Texas, but similar PA requirements apply where coverage exists.

Note: Most Humana members in Texas have Medicare Advantage plans, which combine medical and prescription coverage under unified prior authorization processes.

Cimzia Formulary Status & Tier Placement

Coverage Status

Cimzia is included on Humana's 2024 Medicare formularies but requires prior authorization across plan types. The medication is generally placed on higher formulary tiers, meaning higher out-of-pocket costs compared to preferred alternatives.

Preferred vs. Non-Preferred Status

Cimzia is typically classified as non-preferred within the anti-TNF biologic class. Humana's preferred agents usually include:

  • Adalimumab biosimilars (various -xxxx designations)
  • Infliximab biosimilars
  • Etanercept in some cases

Alternative Agents

If Cimzia is denied, your doctor may need to consider these Humana-preferred options:

  • Anti-TNF biosimilars (first-line per step therapy)
  • Other biologic classes depending on your condition (IL-17 inhibitors, IL-23 inhibitors)
  • Traditional DMARDs for rheumatoid arthritis

Prior Authorization & Step Therapy Requirements

Step Therapy Protocol

Humana requires step therapy for anti-TNF biologics as of 2025. This means you must typically try and fail preferred agents before Cimzia approval, unless medical exceptions apply.

Required documentation for step therapy exceptions:

  • Contraindications to preferred agents
  • Previous treatment failures with specific dates and reasons
  • Intolerance or adverse reactions to biosimilars
  • Clinical rationale for Cimzia specifically

Medical Necessity Criteria

Your prescriber must document:

  • Appropriate diagnosis: Moderate to severe Crohn's disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, or plaque psoriasis
  • Disease severity: Lab values, imaging results, functional assessments
  • Treatment history: Previous therapies tried, durations, and outcomes
  • Contraindications: Why preferred agents aren't suitable

Specialty Pharmacy Network

Humana's Preferred Network

CenterWell Specialty Pharmacy is Humana's owned specialty pharmacy and offers:

  • Personalized clinical support
  • Financial assistance program navigation
  • Direct coordination with your healthcare team
  • Home delivery to your preferred location

Alternative Network Options

While specific preferred partner agreements weren't detailed in available sources, common specialty pharmacies that may be in-network include:

  • CVS Specialty (verify network status)
  • Accredo (verify network status)
Tip: Always confirm network status before filling to avoid unexpected out-of-pocket costs. Use Humana's pharmacy finder tool to locate in-network specialty pharmacies in Texas.

Cost-Share Basics

Typical Cost Structure

  • Deductible: May apply before coverage begins
  • Copay/Coinsurance: Varies by formulary tier and plan type
  • Out-of-pocket maximum: Annual limit on your total costs

Cost-Saving Options

Manufacturer Support: UCB offers patient assistance programs for eligible patients. Check their official website for current programs and eligibility requirements.

Medicare Extra Help: Low-income Medicare beneficiaries may qualify for reduced prescription costs through the Low Income Subsidy (LIS) program.

Educational Note: This information is for educational purposes only and not financial advice. Consult your plan documents for specific cost-sharing details.

Submission Process & Required Forms

Prior Authorization Submission

For Providers:

  1. Complete Humana's prior authorization form (plan-specific)
  2. Include medical necessity letter
  3. Attach supporting clinical documentation
  4. Submit via Humana provider portal or designated fax line

Required Documentation:

  • Patient demographics and insurance information
  • Diagnosis with ICD-10 codes
  • Previous treatment history with dates and outcomes
  • Clinical notes supporting medical necessity
  • Relevant lab results or imaging studies

Key Form Fields

When completing PA requests, ensure accuracy in:

  • Drug name and NDC/J-code: J0717 for Cimzia
  • Dosing and frequency: Per FDA labeling
  • Diagnosis codes: Must match approved indications
  • Prior therapy documentation: Specific agents, dates, and outcomes

Common Approval Patterns

Strong Submissions Include:

  1. Clear diagnosis documentation with appropriate severity markers
  2. Comprehensive treatment history showing inadequate response to preferred agents
  3. Specific clinical rationale for Cimzia over alternatives
  4. Supporting guideline references from relevant medical societies
  5. Complete prescriber attestation of medical necessity

Red Flags That Lead to Denials:

  • Missing TB/HBV screening documentation
  • Inadequate prior therapy trials
  • Off-label use without strong clinical justification
  • Incomplete diagnosis or severity documentation

Appeals Process in Texas

Internal Appeals Timeline

Medicare Part D: 65 days from denial notice to file appeal; Humana must respond within 7 calendar days for standard requests.

Expedited Appeals: Available when delay could jeopardize health; faster turnaround times apply.

External Review Rights in Texas

If Humana denies your internal appeal, Texas residents have strong external review rights:

  • Independent Review Organization (IRO) review available for medical necessity disputes
  • Timeline: Up to 4 months from final denial to request external review
  • Cost: Insurer pays for IRO review
  • Binding decision: If IRO overturns denial, Humana must comply

Texas Department of Insurance Contact:

  • Consumer helpline: 1-800-252-3439
  • IRO information line: 1-866-554-4926

Who Can File Appeals

Appeals can be submitted by:

  • You (the patient)
  • Your appointed representative
  • Your prescribing physician
Important: ERISA self-funded employer plans follow federal appeals rules, not Texas state processes.

Medical Necessity Documentation

Physician Letter Template

Essential Elements to Include:

  • Patient identification and diagnosis
  • Previous treatment failures with specific details
  • Clinical rationale for Cimzia
  • Supporting literature or guidelines
  • Prescriber contact information

Sample Structure:

"This patient has moderate to severe [condition] despite appropriate trials of [list specific agents with dates and outcomes]. Cimzia is medically necessary because [specific clinical rationale]. Alternative therapies are contraindicated/ineffective due to [documented reasons]."

Supporting Documentation Checklist

  • Complete medical history
  • Laboratory results (inflammatory markers, liver function, etc.)
  • Imaging studies if relevant
  • Previous prescription records
  • Documentation of treatment failures or intolerances
  • Current symptom assessment

FAQ

How long does Humana prior authorization take in Texas? Standard PA requests: up to 30 days for pre-service decisions. Expedited requests when delay could harm health: typically 24-72 hours.

What if Cimzia is non-formulary on my plan? You can request a formulary exception with strong medical necessity documentation. Your doctor must demonstrate why formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, if applying standard timeframes could seriously jeopardize your health. Both internal and external reviews can be expedited in urgent situations.

Does step therapy apply if I've used Cimzia before? Generally, patients already on non-preferred drugs before new step therapy requirements are "grandfathered" and don't need to restart the process.

What happens during a peer-to-peer review? Your prescribing physician speaks directly with a Humana medical director to discuss your case. This often occurs before formal denials and can resolve coverage issues quickly.

How do I find Texas-specific appeal forms? Visit the Texas Department of Insurance website or call their consumer helpline at 1-800-252-3439 for current forms and guidance.

From Our Advocates

"We've seen many Cimzia approvals succeed when prescribers clearly document why biosimilar alternatives failed or caused intolerance. The key is specific dates, dosages, and clinical outcomes rather than general statements. Strong submissions often include recent lab work showing ongoing disease activity despite conventional therapy."

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Our platform helps patients and providers navigate complex prior authorization requirements and appeal processes, ensuring that medically necessary treatments like Cimzia reach the patients who need them. Learn more about our services.

When facing a Cimzia denial from Humana in Texas, remember that you have multiple levels of appeal available, including Texas's robust external review process. The key to success is thorough documentation, understanding your plan's specific requirements, and knowing your rights under both federal and Texas state law.

For complex cases or repeated denials, consider working with Counterforce Health to develop a comprehensive appeal strategy that addresses your plan's specific coverage criteria and leverages the strongest available clinical evidence.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical, legal, or financial advice. Insurance coverage policies change frequently. Always verify current requirements with your specific plan and consult healthcare professionals for medical decisions. For personalized assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439 or visit www.tdi.texas.gov.

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