By Counterforce Health Team in Cimzia (certolizumab pegol) —

How to Get Cimzia Covered by Blue Cross Blue Shield in Washington: Prior Auth, Appeals, and Cost-Saving Strategies

Quick Answer: Getting Cimzia Covered by Blue Cross Blue Shield in Washington

Cimzia (certolizumab pegol) requires prior authorization from Blue Cross Blue Shield plans in Washington and is typically placed on specialty tier formularies. To get approved: (1) Have your provider submit a PA request with diagnosis documentation and prior therapy failures, (2) Use specialty mail-order pharmacy only, and (3) Apply for UCB's CIMplicity copay program if commercially insured. If denied, file internal appeals within 180 days, then request external review through Washington's Office of the Insurance Commissioner. Start with your provider's prior authorization submission today.

Table of Contents

What Drives Cimzia Costs with Blue Cross Blue Shield

Understanding your Blue Cross Blue Shield plan's benefit design helps predict Cimzia costs and approval likelihood. As of February 2025, Cimzia has moved to nonpreferred specialty status across most BCBS commercial plans, increasing out-of-pocket costs.

Formulary Tier Impact

Plan Type Cimzia Tier Typical Cost Share Prior Auth Required
Regence BlueShield Specialty (Tier 4-5) 28% coinsurance Yes
Premera Blue Cross Specialty 25-40% coinsurance Yes
BCBS Medicare Varies by plan $200-600/month Yes
Note: Exact tiers vary by specific plan. Check your Summary of Benefits or use your insurer's drug lookup tool for precise cost estimates.

Step Therapy Requirements

Most Washington BCBS plans require trying preferred alternatives before approving Cimzia:

  • First-line: Methotrexate, sulfasalazine (for RA/IBD)
  • Preferred biologics: Adalimumab biosimilars, infliximab biosimilars
  • Cimzia approval: After documented failure or contraindication to 1-2 preferred options

Investigating Your Benefits

Before starting Cimzia, gather this information from your BCBS plan:

Essential Questions for BCBS Customer Service

  • Is Cimzia on my 2025 formulary? What tier?
  • What's my specialty drug coinsurance percentage?
  • Which prior therapies must I try first (step therapy)?
  • Can I use retail pharmacy or only specialty mail-order?
  • What's my annual out-of-pocket maximum?

Information to Record

  • Policy number and group ID
  • Specialty pharmacy network (usually Accredo, CVS Specialty, or similar)
  • Prior authorization form name and submission method
  • Appeals deadlines (typically 180 days for internal appeals)
Tip: Log into your BCBS member portal to access your specific formulary and cost calculator tools.

Manufacturer and Financial Assistance

UCB offers substantial cost support for eligible patients, but eligibility rules are strict.

CIMplicity Copay Program

For Commercial Insurance:

  • Eligible patients may pay $0 per dose for up to two years
  • Covers both prefilled syringes and in-office administration costs
  • Not valid for Medicare, Medicaid, or other government programs
  • Apply through your provider or call 1-866-424-6942

Patient Assistance Program (PAP)

For Uninsured/Underinsured:

  • Free medication for qualifying low-income patients
  • Income limits apply (verify with UCB)
  • Call 1-866-424-6942, option 2

Washington State Resources

Prior Authorization Requirements

All Washington BCBS plans require prior authorization for Cimzia. Success depends on thorough documentation.

Required Documentation

Your provider must submit:

  • FDA-approved diagnosis with ICD-10 code (Crohn's disease, rheumatoid arthritis, etc.)
  • Prior therapy history: Names, durations, reasons for discontinuation
  • Clinical notes supporting medical necessity
  • Laboratory results (TB screening, hepatitis B testing required)
  • Treatment goals and monitoring plan

Common Approval Criteria

  • Moderate to severe disease activity
  • Inadequate response to conventional DMARDs
  • Contraindication to preferred biologics
  • Appropriate screening completed
Clinician Corner: Medical necessity letters should cite FDA labeling, ACR guidelines for RA, or AGA guidelines for IBD. Include specific failure details: "Patient discontinued adalimumab after 6 months due to loss of efficacy (DAS28 increased from 3.2 to 5.8)" rather than general statements.

Submission Process

  • Premera Blue Cross: Fax to 1-888-260-9836 or submit via provider portal
  • Regence BlueShield: Use online prior authorization system or contact pharmacy services
  • Standard timeline: 72 hours for routine requests
  • Expedited timeline: 24 hours if delay threatens patient health

Specialty Pharmacy Requirements

BCBS plans typically require specialty medications like Cimzia to be dispensed through designated specialty pharmacies, not retail locations.

Approved Specialty Pharmacies

  • Accredo Specialty Pharmacy (most common BCBS partner)
  • CVS Specialty
  • Walgreens Specialty
  • Plan-specific networks (verify with your BCBS customer service)

Cost Differences

Pharmacy Type Coverage Typical Cost
Specialty Mail-Order Covered Plan coinsurance (e.g., 28%)
Retail Pharmacy Usually not covered Full cash price (~$6,000/month)
Important: Transferring from retail to specialty pharmacy before February 1, 2025, is crucial due to Cimzia's nonpreferred status change.

Appeals Process in Washington

If BCBS denies your Cimzia request, Washington provides multiple appeal levels with specific timelines.

Internal Appeals (BCBS)

Level 1: Standard Review

  • Timeline: File within 180 days of denial
  • Process: Submit written appeal with additional documentation
  • Decision: Within 30 days (15 days for urgent)

Level 2: Peer Review (if available)

  • Request physician-to-physician review
  • Clinical discussion between your doctor and BCBS medical director

External Review (Washington State)

If internal appeals fail, request Independent Review Organization (IRO) review:

  • Eligibility: After completing internal appeals
  • Timeline: 180 days from final internal denial
  • Process: Submit request to Washington Office of Insurance Commissioner
  • Cost: Free to patients
  • Decision: Within 30 days (binding on insurer)

Required Appeal Documentation

  • Original denial letter
  • Complete medical records
  • Updated clinical notes
  • Peer-reviewed literature supporting Cimzia use
  • Provider letter of medical necessity
From our advocates: We've seen many Washington patients succeed at the external review level by including specific guideline citations and detailed prior therapy documentation. One composite case involved a Crohn's patient whose IRO reviewer overturned the denial based on contraindications to infliximab that weren't initially considered by the plan.

Annual Renewal Planning

Plan changes can affect Cimzia coverage year-to-year.

What Can Change

  • Formulary tier (Cimzia moved to nonpreferred in 2025)
  • Prior authorization criteria
  • Specialty pharmacy network
  • Coinsurance percentages

Renewal Checklist

  • Review new formulary in October/November
  • Confirm specialty pharmacy contracts
  • Update prior authorization if criteria changed
  • Budget for potential cost increases

Conversation Scripts

Calling BCBS Customer Service

"Hi, I'm calling about prior authorization requirements for Cimzia, spelled C-I-M-Z-I-A. My policy number is [X]. Can you tell me: Is this medication on my formulary? What tier? Do I need prior authorization? What's my specialty drug coinsurance? Which specialty pharmacies are in-network?"

Provider Peer-to-Peer Request

"I'm requesting a peer-to-peer review for [patient name]'s Cimzia denial. The patient has active Crohn's disease with inadequate response to adalimumab and contraindication to infliximab due to prior hepatitis B exposure. When can we schedule the clinical discussion?"

Pharmacy Transfer Request

"I need to transfer my Cimzia prescription from [current pharmacy] to your specialty pharmacy. My insurance requires specialty dispensing. Can you coordinate the transfer and confirm my copay with the CIMplicity program?"

FAQ

How long does BCBS prior authorization take in Washington? Standard requests: 72 hours. Expedited requests: 24 hours. Submit complete documentation to avoid delays.

What if Cimzia is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Include prior therapy failures and clinical contraindications to preferred alternatives.

Can I get expedited approval if I'm currently on Cimzia? Yes, if switching plans or facing coverage disruption. Check the "urgent" box on PA forms and have your provider attest that delays could harm your health.

Does step therapy apply if I failed biologics outside Washington? Yes, documented failures from any location count toward step therapy requirements. Ensure your new provider has complete records.

How do I file a complaint against BCBS in Washington? Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 or file online at insurance.wa.gov. Include denial letters and correspondence.

What's the success rate for Cimzia appeals in Washington? While specific rates aren't published, Washington's external review process has historically favored patients in medical necessity disputes, especially with thorough documentation.

Getting help with complex prior authorizations and appeals can be overwhelming. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each plan's specific requirements.

For additional support navigating insurance coverage challenges, Counterforce Health's platform provides payer-specific workflows and produces letters that meet procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific plan and individual circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For additional consumer protection resources, contact the Washington State Office of the Insurance Commissioner at 1-800-562-6900.

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