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Cimzia (certolizumab pegol)


Billing

Code: J0717

Description: Certolizumab pegol inj 1mg

Unit: 1 mg

Payment: $4.900

Pay quarter: Q4 2023


Medicare history

Dosage and Frequency

Crohn's Disease (CD)

Induction:
• 400mg SQ at weeks 0, 2, and 4

Maintenance:
• 400mg SQ every 4 weeks

Rheumatoid Arthritis (RA)
Psoriatic Arthritis (PsA)
Ankylosing Spondylitis (AS)
Non-Radiographic Axial Spondyloarthritis (nr-axSpA)

Induction:
• 400mg SQ at weeks 0, 2, and 4

Maintenance:
• 200mg SQ every 2 weeks or 400mg SQ every 4 weeks

Plaque Psoriasis (PsO)

• 400mg SQ every 2 weeks

Calculate drug reimbursement


Total Reimbursement:

$1,960.00

(ASP: $1,849.06, Margin: $110.94)


Code:

J0717

# Units to bill:

400

Prior Authorization

Prior auth criteria for Cimzia may include but is not limited to:


1. Diagnosis of rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis that has been confirmed by laboratory tests or radiographs.

2. Treatment with other disease-modifying antirheumatic drugs (DMARDs) has failed, is contraindicated, or is not tolerated.

3. Patient must be at least 18 years old.

4. Patients must demonstrate an adequate response to their current therapy or have not previously failed an adequate trial of another TNF inhibitor.

5. Patients must have evidence of an inadequate response or intolerance to non-biologic DMARDs.

6. Patient must have a body weight of at least 45 kg.

7. Patients must have evidence of active disease as demonstrated by a minimum of 3 tender joints and 3 swollen joints.

8. The patient must have laboratory tests within normal limits or stabilized prior to initiation of Cimzia therapy.

9. Patient must be informed regarding the risks and benefits of Cimzia therapy and must sign a patient agreement form.


Insurance prior auth guidelines:

Aetna

United Healthcare

Cigna

Anthem


Billable NDCs

50474-0700-62

CIMZIA (UCB, INC.)

400 MG


50474-0710-79

CIMZIA (UCB, INC.)

400 MG


50474-0710-81

CIMZIA (UCB, INC.)

1200 MG



Resources

Drug Enrollment Form

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