cimzia pa form – university of michigan...• methotrexate • cyclosporine y n has your patient...

University of Michigan Prescription Drug Plan Pharmacy Services Portal: https://umich.magellanrx.com/

©2020, Magellan Health, Inc. All rights reserved. Revised: 10/01/2020 | Effective: 10/01/2020

Member’s Last Name: Member’s First Name:

UNIVERSITY OF MICHIGAN – CERTOLIZUMAB PEGOL (CIMZIA®)

Some of the information needed to make a determination for coverage is not specifically requested on the Michigan

Prior Authorization Request Form for Prescription Drugs. To avoid delays in reviewing your request, please make sure to

include all of the following information.

Note: Previous and current treatment history requires confirmation via pharmacy claims or progress notes. Please

include supportive documentation with this request.

For Initial Requests:

Does your patient have a diagnosis of congestive heart failure? Y N

Does your patient have a negative TB test prior to initiating therapy, or have received a complete

treatment course for latent/underlying TB?

Y N

For Initial Crohn’s Disease Requests:

Does your patient have a confirmed diagnosis of moderately to severely active Crohn’s disease? Y N

Has your patient had a previous trial of, or contraindication to, at least ONE of the following without

adequate response:

• Thiopurines (i.e., 6-mercaptopurine or azathioprine)

• Corticosteroids

• Methotrexate

Y N

Has your patient had a previous trial of, or contraindication to, BOTH of the following without

adequate response:

• Humira

• Stelara

Y N

For Initial Rheumatoid Arthritis Requests:

Does your patient have a confirmed diagnosis of moderate to severe Rheumatoid Arthritis? Y N


adequate response:

• Methotrexate

• Leflunomide

• Hydroxychloroquine

• Sulfasalazine

Y N

Continued on next page.

https://umich.magellanrx.com/




Has your patient had a previous trial of, or contraindication to, at least TWO of the following

without adequate response:

• Humira

• Enbrel

• Xeljanz

• Rinvoq

Y N

For Initial Psoriatic Arthritis Requests:

Does your patient have a confirmed diagnosis of active psoriatic arthritis? Y N


adequate response:

• Methotrexate

• Sulfasalazine

• Cyclosporine

• Leflunomide

Y N



• Humira

• Enbrel

• Tremfya

• Stelara

• Xeljanz

Y N

For Initial Ankylosing Spondylitis or nr-axSpA Requests:

Does your patient have a confirmed diagnosis of active ankylosing spondylitis or non-radiographic

axial spondylarthritis?

Y N

Has your patient had a previous trial of, or contraindication to, each of the following without

adequate response:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Either Methotrexate or Sulfasalazine

Y N

For the diagnosis of AS only, has your patient had a previous trial of, or contraindication to, BOTH of

the following without adequate response:

• Humira

• Enbrel

Y N

Continued on next page.





For Initial Plaque Psoriasis Requests:

Does your patient have a confirmed diagnosis of moderate to severe plaque psoriasis? Y N

Do your patient’s psoriatic lesions involve greater than or equal to 10% of body surface area (BSA)

or affect the hands, feet or genital area leading to disability/impact on quality of life?

Y N

Has your patient had a previous trial of, or contraindication to, TWO or more of the following


• PUVA (Phototherapy Ultraviolet Light A), UVB (Ultraviolet Light B)

• Topical corticosteroids

• Calcipotriene

• Acitretin

• Methotrexate

• Cyclosporine

Y N



• Humira

• Enbrel

• Tremfya

• Skyrizi

• Stelara

Y N

For All Continuation Requests:

Does the patient continue to have a positive clinical response to therapy, as attested to by the

prescribing provider?

Y N

cimzia pa form – university of michigan...• methotrexate • cyclosporine y n has your patient...

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