CommercialPrior AuthHigh impact
Certolizumab Pegol (Cimzia) (CPB 0761, reviewed 2026-07-01)
Aetna·Rheumatology, Gastroenterology, Dermatology +1 more·Medical Policy
Effective date
Jul 1, 2026
We identified it
Aug 12, 2026
Summary
Aetna has updated its Certolizumab Pegol (Cimzia) coverage policy to restrict approval to members with contraindication, intolerance, or inadequate response to specific lower-cost targeted immune modulators. The policy now requires documented trials of multiple alternative biologics before Cimzia approval for Crohn's disease, rheumatoid arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and polyarticular juvenile idiopathic arthritis. Precertification remains mandatory for all prescriptions.
Action Required
By July 1, 2026: Billing and prior authorization teams must update Aetna authorization workflows to enforce the new step-therapy requirements for Cimzia (Certolizumab Pegol). For all six covered indications (RA, pJIA, PsA, AS/axial spondyloarthritis, Crohn's disease, and plaque psoriasis), require providers to document failed trials or documented contraindications/intolerances to ALL specified alternative biologics before approval. Update prior auth denial templates to reference specific alternatives not yet tried. Train clinical staff to request detailed medical records showing the required 1-month trials of each alternative (e.g., Entyvio, Skyrizi, Stelara, Tremfya, Avsola/Inflectra/Renflexis for Crohn's disease). Exception: Waive alternative trial requirements for pregnant or breastfeeding members. Update encounter forms and EMR templates to prompt providers to document biomarker results (RF, anti-CCP, CRP/ESR for RA) and disease activity status. Failure to obtain precertification or provide step-therapy documentation will result in claim denials. Call (866) 752-7021 or fax (888) 267-3277 for precertification submission.