Specialty Quantity Limit Cimzia 2267-H P2023a - Specialty Pharmacy Clinical Policy Bulletins Aetna Non-Medicare Prescription Drug Plan

Specialty Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan

Subject: Specialty Quantity Limit Cimzia 2267-H P2023a

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.

III. COVERED QUANTITIES

Medication	Standard Limit	Exception Limit*	FDA-recommended dosing
Cimzia starter kit (contains six 200 mg per 1 mL prefilled syringes)	1 kit (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, 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 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 may be considered pJIA • 10 kg (22 lb) to less than 20 kg (44 lb): 100 mg at weeks 0, 2, and 4, followed by 50 mg every other week • 20 kg (44 lb) to less than 40 kg (88 lb): 200 mg at weeks 0, 2, and 4, followed by 100 mg every other week • Greater than or equal to 40 kg (88 lb): 400 mg at weeks 0, 2, and 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, pJIA = polyarticular juvenile idiopathic arthritis
*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:

Cimzia [package insert]. Smyrna, GA: UCB, Inc.; September 2024.

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.

November 04, 2024

Additional Information

Clinical Policy Bulletin Notes

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