Certolizumab Pegol (Cimzia) — CPB 0761 | AETNA Coverage Update

Aetna modified CPB 0761 for certolizumab pegol (Cimzia), effective March 5, 2026. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its Cimzia coverage policy under CPB 0761 Aetna system on March 5, 2026. This change affects certolizumab pegol billing across rheumatology, gastroenterology, dermatology, and oncology practices. The primary billing code is HCPCS J0717 (injection, certolizumab pegol, 1 mg), with supporting diagnostic codes spanning RA, psoriatic arthritis, Crohn's disease, plaque psoriasis, and several off-label indications.

---

Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Certolizumab Pegol (Cimzia)
Policy Code	CPB 0761
Change Type	Modified
Effective Date	March 5, 2026
Impact Level	High
Specialties Affected	Rheumatology, Gastroenterology, Dermatology, Oncology, Hematology
Key Action	Confirm biomarker testing documentation and step-therapy history are on file before submitting precertification for J0717

---

Aetna Certolizumab Pegol Coverage Criteria and Medical Necessity Requirements 2026

Precertification is required for all Aetna members on applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277. Missing this step before dispensing Cimzia means a claim denial — full stop.

The prescriber specialty requirement is the first gate. Aetna will not approve certolizumab pegol unless the prescribing physician matches the indication:

If the prescribing provider doesn't match the indication, prior authorization will fail before anyone even looks at the clinical criteria. Check this before you build the auth request.

Rheumatoid Arthritis: The Biomarker and Step-Therapy Requirements

RA is the most complex pathway in this policy. Aetna considers Cimzia medically necessary for RA under two routes.

Route 1 (Easier): The member received a biologic or targeted synthetic DMARD — such as Rinvoq (upadacitinib) or Xeljanz (tofacitinib) — for moderately to severely active RA within the past 120 days. If that's documented, you can skip the biomarker and step-therapy requirements.

Route 2 (More complex): If the member hasn't had a prior biologic or targeted synthetic, Aetna requires both biomarker testing AND documented step-therapy failure.

For biomarkers, the member must meet one of these two standards:

#	Covered Indication Copy
1	Tested positive for either rheumatoid factor (RF, CPT 86430 or 86431) or anti-CCP (CPT 86200); or
2	Tested for all three: RF, anti-CCP, and CRP (CPT 86140/86141) and/or ESR (CPT 85651/85652) — regardless of results

The real issue here is documentation. Aetna wants to see that testing happened. A negative RF alone isn't disqualifying if CRP and ESR were also run. Make sure the lab reports are in the chart and referenced in your auth submission.

Step-therapy under Route 2 requires a 3-month trial of methotrexate (MTX) at a maximum titrated dose of at least 15 mg per week. The member must have either failed to achieve low disease activity or been unable to tolerate MTX at that dose. From there, Aetna requires failure of, intolerance to, or contraindication to combination therapy with hydroxychloroquine and/or sulfasalazine.

This is layered. If your patient has moderate-to-high disease activity after MTX, that satisfies the step-therapy requirement without needing to document combo DMARD failure. Document disease activity scores — DAS28, CDAI, or equivalent — not just clinical impressions.

Crohn's Disease, Psoriasis, and Other Indications

For Crohn's disease, Aetna follows a similar conventional-therapy-first model. Gastroenterologist prescribing is required. Documentation of prior conventional therapy failure is standard prior authorization territory for biologics here — if your GI practice already precertifies other TNF inhibitors for IBD, the workflow is the same.

Plaque psoriasis approvals require dermatologist prescribing and documented criteria. Check CPB 0761 directly for the full psoriasis pathway, as the policy summary was truncated in the available data.

The immune checkpoint inhibitor (ICI)-related toxicity indication is worth flagging. This is not a widely covered off-label use across all payers. Aetna's CPB 0761 Aetna coverage policy includes it, which is a relatively progressive position. Oncology and hematology practices seeing ICI toxicity patients should note that this is a covered indication — but prior auth is still required, and the prescriber must be an oncologist, hematologist, or rheumatologist.

TB Screening Is a Hard Requirement

Before approving any biologic, Aetna expects evidence of TB screening. CPT codes 86480 and 86481 (IGRA gamma interferon tests) and CPT 86580 (tuberculin skin test, intradermal) are in the policy for this reason. Chest X-rays under CPT 71045–71048 also appear in the supporting codes. If TB screening isn't documented in the precertification request, expect a delay or denial.

---

Aetna Certolizumab Pegol Exclusions and Non-Covered Indications

The policy summary lists several ICD-10 codes that appear in the policy but don't carry covered status — including sarcoidosis (D86.x), microscopic colitis (K52.838–K52.839), severe persistent asthma (J45.50–J45.52), and uveitis (H20.9). These show up in the code set as "other codes related to the CPB," not as covered indications.

That matters for reimbursement. Aetna listing a diagnosis code in the policy document does not mean Cimzia is covered for that diagnosis. It may mean those codes are used for monitoring, screening, or exclusion purposes during review.

If your patient has one of these diagnoses as a secondary condition alongside a covered primary indication, make sure the covered indication is the primary diagnosis on the auth request. Don't let a sarcoidosis code buried in the problem list create ambiguity.

---

Coverage Indications at a Glance

---

Aetna Certolizumab Pegol Billing Guidelines and Action Items 2026

These are the steps your billing and auth teams need to take now, before the March 5, 2026 effective date has passed and claims start hitting the clearinghouse.

Copy Action Items

---

CPT, HCPCS, and ICD-10 Codes for Certolizumab Pegol Under CPB 0761

Primary HCPCS Code — Covered When Selection Criteria Are Met

Code	Type	Description Copy
J0717	HCPCS	Injection, certolizumab pegol, 1 mg

Supporting CPT Codes Related to CPB 0761

Comparator and Step-Therapy HCPCS Codes (Referenced in Policy — No Specific Coverage Group)

Key ICD-10-CM Diagnosis Codes Referenced in CPB 0761

---