Medicare AdvantagePrior AuthMedium impact
Cimzia (certolizumab pegol) (Revised)
Humana·Rheumatology, Gastroenterology, Dermatology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana has revised their prior authorization requirements for Cimzia (certolizumab pegol) for Medicare Advantage plans, effective January 1, 2026. The policy establishes specific step therapy requirements that vary by condition and whether the drug is covered under Part D (pharmacy) or Part B (medical) benefits.
Action Required
By January 1, 2026: Billing team must update prior authorization workflows for Cimzia requests to verify patients have failed required step therapy medications based on their specific diagnosis (Crohn's, psoriatic arthritis, rheumatoid arthritis, etc.) and benefit type (Part D vs Part B). Create diagnosis-specific checklists showing required prior medications for each condition. Train staff to identify whether Cimzia falls under Part B (medical) or Part D (pharmacy) coverage as step therapy requirements differ significantly between benefit types.