By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (Certolizumab Pegol) Covered by UnitedHealthcare in New Jersey: Appeals, Forms & Success Strategies

Quick Answer: Getting Cimzia Covered by UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization for Cimzia (certolizumab pegol) and commonly denies initial requests due to step therapy requirements. Your fastest path: Have your doctor submit a prior authorization with documentation of failed TNF inhibitors (like Humira biosimilars) and complete TB/hepatitis B screening. If denied, appeal immediately—UnitedHealthcare overturns 85.2% of appealed denials. In New Jersey, you have up to 180 days for external review through the Independent Health Care Appeals Program (IHCAP) after completing internal appeals.

Start today: Call UnitedHealthcare member services at the number on your card to confirm your plan's specific prior authorization requirements.

Table of Contents

When Alternatives Make Sense

UnitedHealthcare typically requires patients to try formulary-preferred TNF inhibitors before approving Cimzia. This step therapy approach makes clinical sense in many cases, as adalimumab (Humira) and its biosimilars, etanercept (Enbrel), and infliximab (Remicade) show comparable efficacy to Cimzia for approved indications like rheumatoid arthritis and Crohn's disease.

However, alternatives may not be appropriate if you have:

  • Previous treatment failure with other TNF inhibitors
  • Contraindications to preferred agents (e.g., heart failure with certain TNF inhibitors)
  • Pregnancy considerations (Cimzia's unique Fc-free structure may be preferred)
  • Injection site reactions or allergies to other formulations
Note: Enbrel (etanercept) is not approved for Crohn's disease or ulcerative colitis, so it wouldn't be a step therapy requirement for inflammatory bowel disease patients.

Typical Alternatives by Drug Class

TNF Inhibitors (Same Mechanism as Cimzia)

  • Adalimumab (Humira) and biosimilars: Every 2 weeks, subcutaneous
  • Etanercept (Enbrel): Weekly, subcutaneous
  • Infliximab (Remicade) and biosimilars: Every 4-8 weeks, IV infusion
  • Golimumab (Simponi): Monthly, subcutaneous

Non-TNF Biologics (Different Mechanisms)

  • Ustekinumab (Stelara): IL-12/23 inhibitor
  • Tocilizumab (Actemra): IL-6 inhibitor
  • Rituximab: B-cell depleting agent (for RA)

JAK Inhibitors (Oral Options)

  • Tofacitinib (Xeljanz), baricitinib (Olumiant), upadacitinib (Rinvoq)

The choice depends on your specific condition—UnitedHealthcare's formulary typically favors biosimilars when available due to cost savings.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must get approval before prescribing UnitedHealthcare provider portal UHC Provider Guide
Step Therapy Try preferred drugs first Plan formulary document UHC Commercial Formulary
TB/HBV Screening Required before any TNF inhibitor FDA prescribing information CMS Quality Measure 275
Diagnosis Documentation ICD-10 codes for approved indications Medical records FDA Access Data
Appeals Deadline (Internal) 180 days from denial notice Member handbook UHC Administrative Guide
External Review (NJ) 180 days after final internal denial IHCAP program NJ DOBI

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

Timeline: 1-2 days
Documents needed: Insurance card, complete medical history, lab results for TB/hepatitis B screening
Submit via: Bring to your doctor's appointment

2. Complete Medical Screening (Clinic)

Timeline: 1-2 weeks
Required tests: Tuberculosis skin test or IGRA, hepatitis B surface antigen, core antibody, and surface antibody
Submit via: Lab orders through your healthcare provider

3. Document Step Therapy Trials (Clinic)

Timeline: Ongoing documentation
Requirements: Records of failed or contraindicated TNF inhibitors
Submit via: Medical records and prior authorization form

4. Submit Prior Authorization (Clinic)

Timeline: 2-5 business days for determination
Documents: PA form, medical necessity letter, lab results, treatment history
Submit via: UnitedHealthcare provider portal (verify current link)

5. Monitor Decision (Patient + Clinic)

Timeline: UHC must respond within plan timelines (typically 72 hours for urgent, 15 days for standard)
Track via: Provider portal or member services call
Next step: If approved, coordinate with specialty pharmacy; if denied, proceed to appeal

Exception Strategy for Direct Cimzia Access

When standard step therapy isn't appropriate, your doctor can request an exception by documenting:

Medical Contraindications:

  • Heart failure severity that contraindicates other TNF inhibitors
  • Previous serious adverse reactions to preferred agents
  • Drug interactions with other medications

Prior Treatment Failures:

  • Lack of efficacy with adequate trial duration (typically 12-16 weeks)
  • Loss of response after initial improvement
  • Intolerance due to injection site reactions or other side effects

Clinical Urgency:

  • Rapidly progressive disease requiring immediate treatment
  • Risk of permanent joint damage or organ complications
  • Counterforce Health helps clinicians build evidence-backed exception requests by analyzing payer policies and identifying the strongest clinical arguments for direct access.
From our advocates: We've seen success when doctors include specific lab values (like elevated CRP or ESR) and imaging results showing active inflammation, rather than just stating "patient failed previous therapy." The more objective data supporting medical necessity, the stronger the case.

Appeals Playbook for New Jersey

Internal Appeals (UnitedHealthcare)

Level 1: File within 180 days of denial notice

  • Submit via: Member portal, fax, or mail (confirm current contact info)
  • Timeline: 15-30 days for standard review, 72 hours for urgent
  • Required: Denial letter, additional medical records, doctor's letter

Level 2: If Level 1 denied

  • Timeline: Same as Level 1
  • Strategy: Include peer-reviewed studies supporting Cimzia use, updated clinical notes

External Review (New Jersey IHCAP)

After completing UnitedHealthcare's internal appeals, New Jersey residents can request external review through the Independent Health Care Appeals Program.

Key Details:

  • Deadline: 180 days from final internal denial
  • Cost: Free to patients (insurers pay all fees)
  • Process: Submit directly to Maximus Federal Services (contracted by NJ)
  • Timeline: 5 business days for acceptance decision, 45 days for full review
  • Success rate: Approximately 50% of external appeals nationwide favor consumers

Required Documents:

  • Final denial letter from UnitedHealthcare
  • All medical records supporting your case
  • Completed external review application
  • Doctor's letter explaining medical necessity
Tip: New Jersey law requires insurers to comply with favorable external review decisions. The IURO's decision is binding per N.J.S.A. 26:2S-11.

Switching Logistics and Coordination

If you need to try a formulary alternative first, switching between TNF inhibitors typically doesn't require a washout period. Clinical studies show immediate switching between Cimzia and other TNF inhibitors is safe, with 85.2% of switches showing no increased infection risk.

Coordination Steps:

  1. Pharmacy: Contact specialty pharmacy 1-2 weeks before switch
  2. Insurance: Ensure new drug is pre-authorized
  3. Monitoring: Schedule follow-up within 4-6 weeks of switch
  4. Documentation: Keep detailed records of response/side effects for potential Cimzia reauthorization

Timeline: Most switches can occur within 1-2 weeks of last dose, minimizing disease flare risk.

Re-trying for Cimzia Later

If you start with an alternative TNF inhibitor, document everything for a future Cimzia request:

Track During Alternative Therapy:

  • Disease activity scores (DAS28, CDAI, etc.)
  • Quality of life measures
  • Side effects and tolerability issues
  • Laboratory monitoring results
  • Reasons for discontinuation or switch

Reauthorization Triggers:

  • Primary non-response (no improvement after 12-16 weeks)
  • Secondary loss of response (initial improvement followed by worsening)
  • Intolerable side effects
  • Contraindication development (e.g., new heart failure diagnosis)

Counterforce Health specializes in turning these documented treatment failures into compelling prior authorization requests, using payer-specific language and evidence requirements.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Missing TB/HBV screening Submit completed screening results Lab reports showing negative TB test, HBV panel
Lack of step therapy Document failed trials of preferred drugs Treatment records, response measurements
Insufficient diagnosis severity Provide objective disease measures Lab values (CRP, ESR), imaging, activity scores
Non-formulary status Request formulary exception Medical necessity letter, clinical studies
Quantity limits exceeded Justify higher dosing FDA prescribing information, clinical guidelines

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in New Jersey?
Standard requests: 15 days maximum. Urgent requests: 72 hours. UnitedHealthcare must notify you of delays and provide interim coverage for urgent cases.

What if Cimzia is non-formulary on my plan?
You can request a formulary exception with medical necessity documentation. Non-formulary doesn't mean uncovered—it typically means higher cost-sharing and additional approval requirements.

Can I request an expedited appeal?
Yes, if delay would seriously jeopardize your health. Expedited appeals must be processed within 72 hours for urgent medical situations.

Does step therapy apply if I failed TNF inhibitors outside New Jersey?
Treatment history from other states counts toward step therapy requirements. Ensure your doctor includes complete records from previous providers.

What's UnitedHealthcare's appeal success rate?
UnitedHealthcare overturns 85.2% of appealed prior authorization denials—higher than the industry average of 81.7%.

How much does Cimzia cost without insurance?
UCB lists approximately $5,999.43 for a two-syringe maintenance pack. Patient assistance programs and copay cards may be available through the manufacturer.

Can my doctor call UnitedHealthcare directly?
Yes, peer-to-peer reviews allow your doctor to discuss your case directly with UnitedHealthcare's medical director. Request this option if initial prior authorization is denied.

What if I need Cimzia immediately for a flare?
Request expedited prior authorization and consider bridge therapy with corticosteroids while awaiting approval. Document the urgency clearly in all submissions.

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeal processes for specialty medications like Cimzia. Their platform analyzes payer policies and clinical evidence to create targeted, successful appeals that turn insurance denials into approvals.

Sources & Further Reading

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 company for personalized guidance. For questions about New Jersey insurance appeals, contact the NJ Department of Banking and Insurance at 1-800-446-7467.

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