By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (Certolizumab Pegol) Covered by UnitedHealthcare in New York: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Cimzia Covered by UnitedHealthcare in New York

UnitedHealthcare requires prior authorization for Cimzia (certolizumab pegol) but approves 85.2% of appeals when properly documented. Key requirements: specialist prescription, TB/hepatitis B screening, and proof of failed conventional therapies. Submit via UHC provider portal with complete medical records. If denied, New York's external appeal through the Department of Financial Services offers binding review within 30 days. First step: Contact your rheumatologist or gastroenterologist to order TB/HBV labs and gather documentation of prior treatment failures.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Required Screening Tests
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Process in New York
  6. Cost-Saving Options
  7. When to Escalate
  8. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required for all indications UHC Provider Portal 15-30 days standard
Specialist Prescription Rheumatologist, gastroenterologist, or dermatologist Your doctor's credentials Before PA submission
TB Screening Negative within 6-12 months Lab results, chest X-ray Pre-initiation required
Hepatitis B Panel HBsAg, anti-HBc, anti-HBs Lab results Pre-initiation required
Step Therapy Failed conventional therapies Treatment records Varies by indication
Quantity Limits 6 injections initial, then maintenance UHC Dosing Policy Override with PA

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (1-2 weeks)

Who does it: Your specialist and you
Documents needed: Insurance card, complete treatment history, lab orders
Timeline: Schedule within 1 week

Order TB screening (TST/IGRA or chest X-ray) and hepatitis B panel (HBsAg, anti-HBc, anti-HBs). Document all prior treatments with dates, doses, and reasons for discontinuation.

2. Complete Medical Necessity Letter (3-5 days)

Who does it: Your prescribing physician
Required elements: ICD-10 diagnosis code, disease severity, failed therapies, contraindications to alternatives
Submit via: UHC provider portal

Clinician Corner: Include specific dates of prior TNF inhibitor trials (e.g., "Failed adalimumab 40mg every other week from 1/2024-6/2024 due to inadequate response with CRP remaining elevated at 15 mg/L").

3. Submit Prior Authorization (Same day)

Who does it: Healthcare provider
Portal: UHC Provider Portal
Include: PA form, medical necessity letter, lab results, treatment history

4. Track Status and Respond to Requests (Ongoing)

Timeline: Check portal every 2-3 days
Response required: Within 24-48 hours for additional information requests

5. Request Peer-to-Peer if Denied (Within 30 days)

Who initiates: Prescribing physician
Format: Direct phone discussion with UHC medical director
Success rate: High when clinical rationale is clear

Required Screening Tests

Tuberculosis Screening

  • Tests accepted: Tuberculin skin test (TST), interferon-gamma release assay (IGRA), or chest X-ray
  • Timing: Within 6-12 months before initiation
  • Positive result action: Complete anti-TB treatment before starting Cimzia
  • Documentation: Submit lab reports and any treatment records

Hepatitis B Screening

  • Required tests: HBsAg (surface antigen), anti-HBc (core antibody), anti-HBs (surface antibody)
  • Positive carrier management: Antiviral prophylaxis or hepatology consultation required
  • Documentation: Complete panel results with interpretation
Note: According to the FDA label, patients with active TB or serious infections should not receive Cimzia. Latent TB must be treated before initiation.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing TB/HBV screening Submit complete lab results TST/IGRA results, hepatitis B panel, chest X-ray if indicated
Inadequate step therapy Document failed conventional therapies Treatment dates, doses, duration, reasons for discontinuation
Non-formulary status Request formulary exception Medical necessity letter emphasizing unique benefits of Cimzia
Quantity limit exceeded Request override for loading dose Dosing schedule per FDA label (400mg weeks 0, 2, 4)
Concurrent biologic use Confirm no overlapping therapies Current medication list, discontinuation dates

Appeals Process in New York

Internal Appeals (UnitedHealthcare)

  • Level 1: Submit within 180 days of denial
  • Timeline: 15-30 days (72 hours for expedited)
  • Required: Denial letter, updated medical records, physician rationale
  • Success rate: 85.2% overturn rate when properly documented

External Appeals (New York State)

  • Agency: New York Department of Financial Services
  • Deadline: 4 months after final internal denial
  • Cost: Up to $25 (waived for Medicaid/hardship)
  • Timeline: 30 days standard, 72 hours expedited
  • Decision: Binding on UnitedHealthcare
Expedited Appeals: Available when delay would jeopardize health. Submit Comprehensive Physician Attestation Form with clinical justification.

For help with appeals: Contact Community Health Advocates at 888-614-5400 for free assistance with New York insurance appeals.

Cost-Saving Options

Manufacturer Support

  • CIMplicity Program: Patient support services and potential cost assistance
  • Copay card: May reduce out-of-pocket costs for eligible patients
  • Contact: Visit cimzia.com or call manufacturer directly

Foundation Assistance

Check eligibility for patient assistance programs through:

  • Good Days Foundation
  • Patient Access Network Foundation
  • HealthWell Foundation

When to Escalate

Contact the New York Department of Financial Services if:

  • UnitedHealthcare misses appeal deadlines
  • Required forms are not provided
  • Inappropriate denial patterns occur

File a complaint: DFS Consumer Portal or call (800) 400-8882

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in New York? Standard PA decisions take 15-30 days. Expedited reviews (when health is at risk) are completed within 72 hours.

What if Cimzia is not on my formulary? Request a formulary exception with your PA submission. Emphasize medical necessity and unique benefits compared to formulary alternatives.

Can I appeal if I've failed therapies outside New York? Yes, treatment records from any state are valid. Include complete documentation with dates and outcomes.

Does step therapy apply to all Cimzia indications? For Crohn's disease, you must show inadequate response to conventional therapies. Other indications may have different requirements per UHC policy.

What happens if my appeal is denied? After exhausting internal appeals, you can file an external appeal with New York DFS. Their decision is binding on UnitedHealthcare.

How do I request expedited review? Have your physician submit documentation that delay would jeopardize your health. Include specific clinical details about disease progression or complications.

About Counterforce Health: Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by creating targeted, evidence-backed rebuttals aligned to each payer's specific requirements. Our platform analyzes denial reasons and crafts point-by-point responses using the right clinical evidence and procedural requirements.

For complex denials or multiple failed appeals, services like Counterforce Health can help draft payer-specific appeals that address UnitedHealthcare's exact criteria and improve approval odds.

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 change. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For the most current New York insurance regulations, visit the Department of Financial Services website.

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