Cimzia® (certolizumab)

Authorization forms

(authorization is required for both pharmacy and medical coverage)

Traditional & Optimized (01/2019)

Medicaid (07/2019)

Medicare Part B and Part D (01/2019)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

For further information, please see the Injectable Drugs page

Code(s): J0717

Benefit:

  • Medical benefit if administered by health professional
  • Pharmacy benefit if self-injected

Notes: Per 1 mg; treatment of moderate to severe Crohn's disease and rheumatoid arthritis.