Certolizumab pegol

This policy covers certolizumab pegol (Cimzia®) for FDA‑labeled indications—including moderately to severely active Crohn’s disease, rheumatoid arthritis, active polyarticular juvenile idiopathic arthritis (age ≥2 years), psoriatic arthritis, ankylosing spondylitis/non‑radiographic axial spondyloarthritis with objective inflammation, and moderate‑to‑severe plaque psoriasis—when therapy is proven effective and the proposed dose, frequency, and duration align with authoritative sources. Coverage is subject to the member’s benefit plan/contract and state rules; off‑label use is covered only if supported by recognized compendia or two qualifying peer‑reviewed articles, non‑FDA‑approved uses are considered experimental and not covered, and administration/coverage (e.g., self‑administration under pharmacy benefit) follows plan-specific requirements.

"Drug therapy that is proven effective for the relevant diagnosis or procedure."