Does J0717 require prior authorization?

Yes, J0717 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for J0717?

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

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`J0717`, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation of prior therapies tried and response is required for initial RA requests.
Continuation requires chart notes documenting positive clinical response.

Key Coverage Criteria

Indication: Crohn’s disease (CD) – for initial therapy, diagnosis of moderately to severely active CD; inadequate response to conventional therapies; Cimzia initiated and titrated per FDA-labeled dosing for CD; not on a systemic targeted immunomodulator for same indication.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
medically necessary for FDA-labeled indications: Crohn’s disease (adult, moderate-severe, inadequate response to conventional therapy), rheumatoid arthritis (adult), polyarticular juvenile idiopathic arthritis (pJIA, age 2+), psoriatic arthritis (adult), ankylosing spondylitis (adult), non-radiographic axSpA with objective signs of inflammation (adult), plaque psoriasis (adult)
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).

20 Active Policies

ARKBLUE-CERTOLIZUMAB-PEGOL-E-G-CIMZIA-179F12A3E2, Certolizumab pegol (e.g., Cimzia)

FLORIDA_BLUE-FLBLUE-CIMZIA-CERTOLIZUMAB-PEGOL-BEDC986432, Cimzia (certolizumab pegol)

BCBSLA-00200-2D13E294AE, 00200 certolizumab pegol (Cimzia)

BCBSM-2049833-E9C7EDB546, CIMZIA (CERTOLIZUMAB PEGOL)

POINT32HEALTH-PMNG-22911, Cimzia (certolizumab pegol)

MULTI

BCBSND-CERTOLIZUMAB-CIMZIA-68DD38430B, Certolizumab Cimzia

BCBSNJ-DRUGS-059-C669BBD663, Certolizumab Pegol (Cimzia)

MODA-CIMZIA-042D5778DF, Cimzia (certolizumab pegol)

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSNM-RX501.111, Certolizumab Pegol

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.111, Certolizumab Pegol

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-cimzia, Cimzia (Certolizumab Pegol)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-cimzia, Cimzia (Certolizumab Pegol)

BCBSTN-c2cf5311ee, Certolizumab Pegol (Cimzia)

UHC-COMM-MD-CIMZIA-CERTOLIZUMAB-PEGOL-COMMUNITY-PLAN-567C4A0153, Cimzia (Certolizumab Pegol) – Community Plan Medical Benefit Drug Policy

UHC-POL-cimzia, Cimzia (Certolizumab Pegol)

UHC-EXCH-MD-CIMZIA-CERTOLIZUMAB-PEGOL-INDIVIDUAL-EXC-EC8D619DB0, Cimzia (Certolizumab Pegol) – Individual Exchange Medical Benefit Drug Policy

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Ask Backwork about documentation requirements, denial risks, or coverage in your state.

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J0717, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation of prior therapies tried and response is required for initial RA requests.
Continuation requires chart notes documenting positive clinical response.

Key Coverage Criteria

Indication: Crohn’s disease (CD) – for initial therapy, diagnosis of moderately to severely active CD; inadequate response to conventional therapies; Cimzia initiated and titrated per FDA-labeled dosing for CD; not on a systemic targeted immunomodulator for same indication.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
medically necessary for FDA-labeled indications: Crohn’s disease (adult, moderate-severe, inadequate response to conventional therapy), rheumatoid arthritis (adult), polyarticular juvenile idiopathic arthritis (pJIA, age 2+), psoriatic arthritis (adult), ankylosing spondylitis (adult), non-radiographic axSpA with objective signs of inflammation (adult), plaque psoriasis (adult)
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).

20 Active Policies

ARKBLUE-CERTOLIZUMAB-PEGOL-E-G-CIMZIA-179F12A3E2, Certolizumab pegol (e.g., Cimzia)

FLORIDA_BLUE-FLBLUE-CIMZIA-CERTOLIZUMAB-PEGOL-BEDC986432, Cimzia (certolizumab pegol)

BCBSLA-00200-2D13E294AE, 00200 certolizumab pegol (Cimzia)

BCBSM-2049833-E9C7EDB546, CIMZIA (CERTOLIZUMAB PEGOL)

POINT32HEALTH-PMNG-22911, Cimzia (certolizumab pegol)

MULTI

BCBSND-CERTOLIZUMAB-CIMZIA-68DD38430B, Certolizumab Cimzia

BCBSNJ-DRUGS-059-C669BBD663, Certolizumab Pegol (Cimzia)

MODA-CIMZIA-042D5778DF, Cimzia (certolizumab pegol)

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSNM-RX501.111, Certolizumab Pegol

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.111, Certolizumab Pegol

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-cimzia, Cimzia (Certolizumab Pegol)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-cimzia, Cimzia (Certolizumab Pegol)

BCBSTN-c2cf5311ee, Certolizumab Pegol (Cimzia)

UHC-COMM-MD-CIMZIA-CERTOLIZUMAB-PEGOL-COMMUNITY-PLAN-567C4A0153, Cimzia (Certolizumab Pegol) – Community Plan Medical Benefit Drug Policy

UHC-POL-cimzia, Cimzia (Certolizumab Pegol)

UHC-EXCH-MD-CIMZIA-CERTOLIZUMAB-PEGOL-INDIVIDUAL-EXC-EC8D619DB0, Cimzia (Certolizumab Pegol) – Individual Exchange Medical Benefit Drug Policy

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J0717 Sign up free

`J0717`, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0717`, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0717, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0717, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0717`, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug

`J0717`, Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug