Subject: Specialty Quantity Limit Cimzia 2267-H P2022

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 (3 sets   of 2 syringes) per   28 days	Not applicable	RA/PsA/AS/nr-axSpA   •  Loading doses: 400 mg       (two 200 mg injections)       at weeks 0, 2,   •  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   Plaque 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 kit for   subcutaneous   injection	2 kits (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; nr-axSpA = non-radiographic 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 28, 2023