Certolizumab Pegol (Cimzia®) Restricted Product(S)

Corporate Medical Policy: Certolizumab pegol (Cimzia®) Restricted Product(s):

• certolizumab pegol (Cimzia®) subcutaneous injection for administration by a healthcare professional

FDA Approved Use: • For the treatment of adults with moderately to severely active rheumatoid arthritis • For the treatment of adults with active psoriatic arthritis • For the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy • For reducing signs and symptoms of Crohn’s disease and maintaining clinical response in adults with moderately to severely active disease who have had an inadequate response to conventional therapy • For the treatment of adults with active ankylosing spondylitis • For the treatment of adults with active non-radiographic axial spondyloarthritis with objective signs of inflammation

Criteria for Medical Necessity: The restricted product(s) may be considered medically necessary when the following criteria are met: 1. The patient has a diagnosis of moderately to severely active rheumatoid arthritis (RA); AND a. The patient is 18 years of age or older; AND b. The patient has tried and had an inadequate response to maximally tolerated methotrexate (e.g., titrated to 25 mg weekly) for at least 3-months [medical record documentation required]; OR c. The patient has tried and had an inadequate response to another conventional agent (i.e., hydroxychloroquine, leflunomide, sulfasalazine) used in the treatment of RA for at least 3-months [medical record documentation required]; OR d. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ALL of the following conventional agents (i.e., methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) used in the treatment of RA [medical record documentation required]; OR

2. The patient has a diagnosis of active psoriatic arthritis (PsA); AND a. The patient is 18 years of age or older; AND b. The patient has tried and had an inadequate response to ONE conventional agent (i.e., cyclosporine, hydroxychloroquine, leflunomide, methotrexate, sulfasalazine) used in the treatment of PsA for at least 3-months [medical record documentation required]; OR

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c. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ALL of the following conventional agents (i.e., cyclosporine, leflunomide, methotrexate, sulfasalazine) used in the treatment of PsA [medical record documentation required]; OR d. The patient has severe active PsA (e.g., erosive disease, elevated markers of inflammation [e.g., ESR, CRP] attributable to PsA, long-term damage that interferes with function [i.e., joint deformities], rapidly progressive) [medical record documentation required]; OR e. The patient has concomitant severe psoriasis (PS) (e.g., greater than 10% body surface area involvement, occurring on select locations [i.e., hands, feet, scalp, face, or genitals], intractable pruritus, serious emotional consequences) [medical record documentation required]; OR

3. The patient has a diagnosis of moderate to severe plaque psoriasis (PS); AND a. The patient is 18 years of age or older; AND b. The patient has tried and had an inadequate response to ONE conventional agent (i.e., acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA [phototherapy], tacrolimus, tazarotene, topical corticosteroids) used in the treatment of PS for at least 3-months [medical record documentation required]; OR c. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ALL conventional agents used in the treatment of PS [medical record documentation required]; OR d. The patient has severe active PS (e.g., greater than 10% body surface area involvement, occurring on select locations [i.e., hands, feet, scalp, face, or genitals], intractable pruritus, serious emotional consequences) [medical record documentation required]; OR e. The patient has concomitant severe psoriatic arthritis (PsA) (e.g., erosive disease, elevated markers of inflammation [e.g., ESR, CRP] attributable to PsA, long-term damage that interferes with function [i.e., joint deformities], rapidly progressive) [medical record documentation required]; OR

4. The patient has a diagnosis of moderately to severely active Crohn’s disease (CD); AND a. The patient is 18 years of age or older; AND b. The patient has tried and had an inadequate response to ONE conventional agent (i.e., 6-mercaptopurine, aminosalicylates, azathioprine, corticosteroids [e.g., prednisone, budesonide EC capsule], mesalamine, methotrexate, sulfasalazine) used in the treatment of CD for at least 3-months [medical record documentation required]; OR c. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ALL of the following conventional agents (i.e., 6- mercaptopurine, azathioprine, corticosteroids [e.g., prednisone, budesonide EC capsule], methotrexate, sulfasalazine) used in the treatment of CD [medical record documentation required]; OR

5. The patient has a diagnosis of active ankylosing spondylitis (AS); AND

a. The patient is 18 years of age or older; AND b. The patient has tried and had an inadequate response to two different NSAIDs used in the treatment of AS for at least a 4-week total trial [medical record documentation required]; OR c. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ALL NSAIDs used in the treatment of AS [medical record documentation required]; OR

6. The patient has a diagnosis of active non-radiographic axial spondyloarthritis (nr-axSpA); AND a. The patient is 18 years of age or older; AND b. The patient has tried and had an inadequate response to two different NSAIDs used in the treatment of nr-axSpA for at least a 4- week total trial [medical record documentation required]; OR c. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ALL NSAIDs used in the treatment of nr-axSpA [medical record documentation required]; AND

7. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., rheumatologist for PsA, RA; gastroenterologist for CD; dermatologist for PS) or has consulted with a specialist in the area of the patient’s diagnosis; AND 8. The patient will NOT be using certolizumab pegol (Cimzia®) in combination with another biologic immunomodulator agent or Otezla; AND 9. The patient does NOT have any FDA labeled contraindications to certolizumab pegol (Cimzia®); AND 10. The patient has been tested for latent tuberculosis (TB) when required by the prescribing information for the requested agent AND if positive the patient has begun therapy for latent TB; AND 11. The requested quantity does NOT exceed the maximum units allowed for the duration of approval (see table below).

Duration of Approval: 365 days (1 year)

FDA Label Reference Medication Indication Dosing HCPCS Maximum Units* RA in patients ≥18 years old SC: 400 mg at day 0, week 2 and 4, 6000 certolizumab pegol then 200 mg every 2 weeks or 400 J0717 (Cimzia®) mg every 4 weeks

PS in patients ≥18 years old SC: 400 mg every 2 weeks; for 10400 weight ≤90 kg: 400 mg at day 0, week 2, and week 4, then 200 mg every 2 weeks can be considered

CD in patients ≥18 years old SC: 400 mg at day 0, week 2, and 6000 week 4, then 400 mg every 4 weeks

AS in patients ≥18 years old SC: 400 mg at day 0, week 2, and 6000 week 4, then 200 mg every 2 weeks or 400 mg every 4 weeks

nr-axSpA in patients ≥18 years old SC: 400 mg at day 0, week 2, and 6000 week 4, then 200 mg every 2 weeks or 400 mg every 4 weeks

*Maximum units allowed for duration of approval

References: all information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information:

August 2021: Criteria change: Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021. June 2021: Criteria change: Medical record documentation required for all indications. April 2021: Criteria change: Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; RA: added option for trial of another conventional agent; PsA: added option for severe active PsA or concomitant severe psoriasis; PS: BSA requirement changed to 10%, added option for concomitant severe PsA; AS: added requirement for trial of two different

NSAIDs or intolerance/contraindication/hypersensitivity to all NSAIDs; nr-axSpA: removed diagnostic criteria and requirement for objective signs of inflammation and radiographic evidence of structural damage; added requirements to be prescribed by or in consultation with a specialist, that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021. *Further historical criteria changes and updates available upon request from Medical Policy and/or Corporate Pharmacy.

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