Does J0717 require prior authorization?

No, J0717 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J0717?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`J0717` — Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For Crohn's disease, documentation of inadequate response to conventional therapies or prior targeted immunomodulator therapy, and consultation with a gastroenterologist when required
"Documentation of positive clinical response" required for continuation of therapy for all covered indications
For prior therapy requirements provide documentation of prior treatment failure or intolerance: examples include inadequate response to conventional therapies (anti-inflammatory drugs, corticosteroids, oral immunosuppressive agents), 3 month trial of a non-biologic DMARD for RA, 3 month methotrexate trial for PsA/PS when required, or two NSAID trials each of at least 4 weeks for AS/nr-axSpA
"Cimzia is initiated and titrated according to US FDA labeled dosing" – documentation of dosing/titration per FDA label

Key Coverage Criteria

Crohn's Disease (CD): "Cimzia is proven for the treatment of Crohn's disease (CD) when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of moderately to severely active Crohn's disease; and Patient has had an inadequate response to conventional therapies (examples include anti-inflammatory drugs, corticosteroids, or oral immunosuppressive agents); and Cimzia is initiated and titrated according to US Food and Drug Administration (FDA) labeled dosing for [...]
Crohn's Disease (medically necessary criteria): "For initial therapy, all of the following: Diagnosis of moderately to severely active Crohn's disease; and One of the following: History of failure to one of the following conventional therapies at up to maximally indicated doses unless contraindicated or clinically significant adverse effects are experienced: Corticosteroids (e.g., prednisone, methylprednisolone, budesonide) 6-mercaptopurine (Purinethol) Azathioprine (Imuran) Methotrexate (Rheuma [...]
Rheumatoid Arthritis (RA): "Cimzia is proven for the treatment of rheumatoid arthritis (RA) when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of moderately to severely active rheumatoid arthritis; and Cimzia is initiated and titrated according to US FDA labeled dosing for RA; and Patient is not receiving Cimzia in combination with a targeted immunomodulator ...; and Initial authorization will be issued for 12 months"
Rheumatoid Arthritis (medically necessary criteria): "For initial therapy, all of the following: Diagnosis of moderately to severely active rheumatoid arthritis; and One of the following: History of failure intolerance to a 3 month trial of one non-biologic disease modifying anti-rheumatic drug (DMARD) [e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine] at maximally indicated doses, unless contraindicated or clinically significant adverse effects are experienced; or Patient has [...]
Psoriatic Arthritis (PsA): "Cimzia is proven for the treatment of psoriatic arthritis (PsA) when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of active psoriatic arthritis; and Cimzia is initiated and titrated according to US FDA labeled dosing for PsA; and Patient is not receiving Cimzia in combination with a targeted immunomodulator ...; and Initial authorization will be issued for 12 months"
Psoriatic Arthritis (medically necessary criteria): "For initial therapy, all of the following: Diagnosis of active psoriatic arthritis; and One of the following: History of failure to a 3 month trial of methotrexate at the maximally indicated dose, unless contraindicated or clinically significant adverse effects are experienced; or Patient has been previously treated with a targeted immunomodulator FDA-approved for the treatment of psoriatic arthritis ...; or Patient is currently on Cimzia and [...]

17 Active Policies

AETNA-CPB-0602 — Intradiscal Procedures

AETNA-CPB-0761 — Certolizumab Pegol (Cimzia)

AETNA-CPB-0788 — Alzheimer's Disease: Experimental Treatments

UHC-POL-cimzia — Cimzia (Certolizumab Pegol)

UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care

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J0717 — Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)