By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia (Certolizumab Pegol) Covered by UnitedHealthcare in Ohio: Prior Authorization, Appeals, and Success Strategies

Answer Box: Getting Cimzia Covered by UnitedHealthcare in Ohio

UnitedHealthcare requires prior authorization for Cimzia (certolizumab pegol) in Ohio, with 12-month approvals based on meeting step therapy requirements and safety screenings. Your fastest path: 1) Submit PA via UnitedHealthcare provider portal with TB/hepatitis B screening, prior therapy failures, and specialist consultation, 2) If denied, file internal appeal within 60 days, 3) Request external review through Ohio Department of Insurance if needed. Start by gathering your diagnosis confirmation, prior treatment records, and lab results today.

Table of Contents

Plan Types & Coverage Implications

UnitedHealthcare offers several plan types in Ohio, each with different coverage pathways for Cimzia:

Commercial Plans (Employer-Sponsored)

  • HMO/PPO/EPO plans all require prior authorization
  • Specialty medications like Cimzia typically processed through OptumRx
  • May require specialist referral (varies by plan)

Medicare Advantage

  • Prior authorization required with potential auto-approval for current users
  • Appeals follow Medicare timelines (30 days standard, 72 hours expedited)
  • Part D coverage through OptumRx with 7-day redetermination process

Medicaid (Ohio Community Plan)

  • State-specific criteria may apply alongside UnitedHealthcare policies
  • 60-day appeal deadline (shorter than federal requirements)
  • Enhanced consumer protections through Ohio Department of Insurance

Formulary Status & Tier Placement

Cimzia appears on UnitedHealthcare formularies as a specialty tier medication requiring prior authorization. The exact tier placement varies by plan, but typically falls under:

  • Specialty Tier: Higher copays/coinsurance
  • Medical Benefit: For provider-administered doses (rare for Cimzia)
  • Pharmacy Benefit: Self-administered subcutaneous injections (standard)

Alternative anti-TNF biologics on formulary include adalimumab (Humira), etanercept (Enbrel), and their biosimilars, which may be preferred for step therapy requirements.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications UHC Provider Portal UHC Policy
Step Therapy Must try preferred alternatives first Plan-specific formulary UHC Provider Resources
Safety Screening TB/Hepatitis B testing within 12 months FDA labeling requirements FDA Access Data
Specialist Consultation Rheumatologist, gastroenterologist, or dermatologist PA form requirements UHC PA Form
Initial Approval 12 months Policy guidelines UHC Policy

Step Therapy & Medical Necessity

By Indication Requirements

Rheumatoid Arthritis

  • Trial of ≥2 preferred TNF inhibitors (adalimumab, etanercept, golimumab)
  • Documented failure, intolerance, or contraindication
  • Cannot combine with other targeted biologics or JAK inhibitors

Crohn's Disease

  • Failure of conventional therapies (corticosteroids, immunomodulators)
  • OR prior treatment with targeted immunomodulator
  • Moderately to severely active disease confirmed

Psoriatic Arthritis

  • Prescribed by/consultation with rheumatologist or dermatologist
  • Similar step therapy requirements as rheumatoid arthritis

Ankylosing Spondylitis

  • Age ≥18 years
  • Refractory to ≥2 NSAIDs at maximum dose for ≥1 month each
  • Rheumatologist consultation required

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Complete diagnosis with ICD-10 codes
    • TB screening (chest X-ray, interferon-gamma release assay)
    • Hepatitis B testing (HBsAg, anti-HBc, anti-HBs)
    • Prior therapy records with dates, doses, and failure reasons
  2. Complete Prior Authorization Form (Prescriber)
  3. Submit Supporting Documentation (Clinic Staff)
    • Medical necessity letter citing disease severity
    • Lab results and imaging studies
    • Specialist consultation notes
    • Prior therapy documentation
  4. Track Submission Status (Patient/Provider)
    • Monitor via UnitedHealthcare provider portal
    • OptumRx decisions typically within 72 hours
    • Call 1-800-711-4555 for status updates
  5. Prepare for Potential Peer-to-Peer (Prescriber)
    • Available for complex cases
    • Direct discussion with UnitedHealthcare medical director
    • Often resolves denials within 5-7 days

Submission Options

  • Online: UnitedHealthcare provider portal (preferred)
  • Fax: 1-866-434-5523 (OptumRx)
  • Phone: 1-800-711-4555
Tip: Electronic submissions through the provider portal process faster and provide real-time status tracking.

Appeals Process in Ohio

Internal Appeals Timeline

Plan Type Filing Deadline Response Time Expedited
Commercial 60 days from denial 30 days (pre-service), 60 days (post-service) 72 hours
Medicare Advantage 60 days 30 days 72 hours
Medicaid Community 60 days 30-45 days 72 hours

Appeals Playbook for UnitedHealthcare in Ohio

Level 1: Internal Appeal

  • File within 60 days of denial notice
  • Submit via UnitedHealthcare provider portal
  • Include additional clinical evidence
  • Response in 30-60 days depending on service type

Level 2: External Review

  • Available after internal denial
  • File with Ohio Department of Insurance
  • Independent Review Organization (IRO) decision
  • Binding on UnitedHealthcare if approved

Expedited Appeals

  • Available when delay could seriously jeopardize health
  • 72-hour response time
  • Can file simultaneously with internal appeal for urgent cases

For patients dealing with complex prior authorization requirements, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each insurer's specific requirements.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Incomplete safety screening Submit TB/HBV results Chest X-ray, IGRA, hepatitis panel within 12 months
Step therapy not met Document prior failures Treatment dates, doses, reasons for discontinuation
Medical necessity unclear Provide disease severity markers Lab values (CRP, ESR), imaging, functional assessments
Missing specialist consultation Obtain specialist evaluation Rheumatologist, gastroenterologist, or dermatologist notes
Prescriber not qualified Verify specialist involvement Specialist prescription or co-signature

Medical Necessity Letter Checklist

Your prescriber's letter should include:

  • Problem: Specific diagnosis with ICD-10 code
  • Prior treatments: Complete history with dates and outcomes
  • Clinical rationale: Why Cimzia is appropriate
  • Guideline citations: FDA labeling, ACR guidelines, or peer-reviewed studies
  • Dosing plan: Proposed regimen and monitoring
  • Prognosis: Expected outcomes without treatment
From our advocates: We've seen that appeals with quantifiable disease activity measures (like CDAI scores for Crohn's or DAS28 for rheumatoid arthritis) alongside photos or functional assessments have higher success rates than those relying solely on subjective symptom descriptions.

Cost-Share Considerations

Cimzia's list price is approximately $5,999 for a two-syringe maintenance pack. Your out-of-pocket costs depend on:

Plan Design

  • Deductible application (high-deductible plans)
  • Specialty tier copay or coinsurance
  • Annual out-of-pocket maximum

Savings Options

  • UCB Patient Support: CimziConnect program offers copay assistance
  • Foundation grants: Patient Advocate Foundation, HealthWell Foundation
  • State programs: Ohio pharmaceutical assistance programs (verify eligibility)

Contact UCB at 1-866-424-6942 for plan-specific coverage assistance and prior authorization support.

When to Escalate

Contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526 if:

  • UnitedHealthcare doesn't respond within required timeframes
  • You believe the denial violates Ohio insurance law
  • You need help filing an external review

Counterforce Health can help analyze your specific denial and develop a targeted appeal strategy that addresses UnitedHealthcare's exact policy requirements.

FAQ

How long does UnitedHealthcare prior authorization take in Ohio? OptumRx typically responds within 72 hours for complete submissions. Standard processing is 30 days for pre-service requests.

What if Cimzia is non-formulary on my plan? Non-formulary medications may still be covered with prior authorization and medical necessity documentation. Request a formulary exception.

Can I request an expedited appeal? Yes, if delay could seriously jeopardize your health. Expedited appeals receive decisions within 72 hours.

Does step therapy apply if I've failed treatments outside Ohio? Yes, documented treatment failures from other states count toward step therapy requirements if properly documented.

What happens if I miss the 60-day appeal deadline? Missing the deadline typically forfeits your appeal rights. Contact Ohio Department of Insurance immediately for guidance on exceptions.

Can my doctor request a peer-to-peer review? Yes, prescribers can request direct discussion with UnitedHealthcare medical directors, often resolving complex cases quickly.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult your healthcare provider and insurance plan documents for specific guidance. For additional support with prior authorization appeals, Counterforce Health provides specialized assistance in navigating insurance coverage challenges for specialty medications.

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