Subject: Specialty Quantity Limit Cimzia 2267-H P2021

Drug

CIMZIA  (certolizumab pegol)

Policy:

      I.  PROGRAM DESCRIPTION

           The standard limit is designed to allow a quantity sufficient for the most
           common uses of the medication. If the member’s plan allows a quantity
           limit exception review for the requested medication, coverage of an
           additional quantity may be provided up to the exception limit with prior
           authorization.  

 

     II.  COVERED QUANTITIES  

Medication	Standard Limit	Exception Limit*	FDA-recommended dosing
Cimzia starter kit   (contains six 200   mg per 1 mL   syringes)	6 syringes per 28   days	Not applicable	RA/PsA/AS/axSpA   •  Loading doses: 400 mg       (two 200 mg injections) at       weeks 0, 2, 4   •  Maintenance dose: 200 mg      every other week or 400      mg every 4 weeks     Crohn’s disease   •  Loading doses: 400 mg       (two 200 mg injections) at       weeks 0, 2, 4   •  Maintenance dose: 400 mg      every 4 weeks based on      clinical response     Psoriasis   •  400 mg (two 200 mg       injections) every other       week   •  For some patients with       body weight ≤ 90 kg: 400      mg at weeks 0, 2, 4      followed by 200 mg every      other week
Cimzia 200 mg per   1 mL prefilled   syringe for   subcutaneous   injection	4 syringes per 28   days	Not applicable
Cimzia kit (contains   two 200 mg vials)	2 kits (4 vials) per  28 days	3 kits (6 vials)   per 28 days

Abbreviations: RA = rheumatoid arthritis; PsA = psoriatic arthritis; AS = ankylosing spondylitis; axSpA = axial spondyloarthritis

*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.

Place of Service:

Outpatient

The above policy is based on the following references:

1.  Cimzia [package insert]. Smyrna, GA: UCB, Inc.; September 2019. 

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

March 16, 2022