ORDERS Call Cancer Center scheduler (831) 622-2744 Treatment Date:_________________________ Fax order to (831) 622-2734 Certolizumab Pegol (Cimzia) Ini�al dose 400 mg subcutaneous at 0,2, and 4 weeks. Certolizumab Pegol (Cimzia) Maintenance dose 200 mg subcutaneous every 2 weeks; OR Certolizumab Pegol (Cimzia) Maintenance dose 400 mg subcutaneous every 4 weeks. **PRIOR AUTHORIZATION NUMBER: ___________________________________________ Expiration of Authorization _________ Primary diagnosis AND Supportive Documentation are REQUIRED PRIMARY DIAGNOSIS – Check one Must send documenta�on of the following criteria with order: √ ICD-10 Descrip�on Cimzia is proven and medically necessary for the ini�al treatment of Rheumatoid Arthri�s (RA) when ALL of the following criteria are met: 1. Diagnosis of moderately to severely ac�ve rheumatoid arthri�s; and 2. Physician a�esta�on that the patient or caregiver is not competent to administer Cimzia FDA labeled for self- administra�on; physician must submit explana�on; and 3. Cimzia is ini�ated and �trated according to US Food and Drug Administra�on labeled dosing for RA; and 4. Pa�ent is not receiving Cimzia in combina�on with either of the following: a. Biologic DMARD [e.g., Actemra (tocilizumab), Enbrel (etanercept), Rituxan (rituximab), Orencia (abatacept)] b. Janus kinase inhibitor [e.g., Xeljanz (tofaci�nib)] and Rheumatoid 5. Ini�al authoriza�on will be issued for 12 months. M06.9 Arthri�s For con�nua�on of therapy when ALL of the following criteria are met: 1. Documenta�on of posi�ve clinical response; and 2. Physician a�esta�on that the pa�ent or caregiver is not competent to administer Cimzia FDA labeled for self- administra�on; physician must submit explana�on; and 3. Cimzia is ini�ated and �trated according to US Food and Drug Administra�on labeled dosing for RA; and 4. Pa�ent is not receiving Cimzia in combina�on with either of the following: a. Biologic DMARD [e.g., Actemra (tocilizumab), Enbrel (etanercept), Rituxan (rituximab), Orencia (abatacept)] b. Janus kinase inhibitor [e.g., Xeljanz (tofaci�nib)] and 5. Authoriza�on will be issued for 12 months. Ordering physician to fill in narra�ve diagnosis if not among the selec�ons, and provide documenta�on to support medical necessity. Orders with diagnoses Other that don’t meet medical necessity will be returned to the physician as not mee�ng medical necessity for treatment. _________ ___________________________________________________________________________________ Time Date Physician signature Print physician full name CERTOLIZUMAB PEGOL (CIMZIA) ORDERS 901533 / 7710 (9/20) .