Cimzia® (certolizumab)

Authorization forms

(authorization is required for both pharmacy and medical coverage)

Traditional & Optimized (09/2018)

Medicare Part B and Part D (01/2019)

Cimzia is not covered for Medicaid

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

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.