HCPCS
J0717
1 mg = 1 unit
Phase 1
Identify what you're billing
Decide medical vs pharmacy benefit before doing anything else — the rest of the workflow depends on it.
Medical benefit (J0717) vs pharmacy benefit (NDC) UCB CIMplicity verified May 2026
The single most important Cimzia billing decision. Get it wrong and the claim denies before any coding question matters.
Cimzia is a subcutaneous biologic with two legitimate dispensing and billing pathways. Which one applies is determined by where the dose is administered and who buys the drug, not by the indication.
| Medical benefit (office-administered) | Pharmacy benefit (home self-inject) | |
|---|---|---|
| Setting | Physician office, infusion suite, clinic, ASC | Patient home (self-injection) |
| Who buys the drug | Provider (buy-and-bill) or specialty pharmacy white-bag/brown-bag | Specialty pharmacy ships to patient |
| Drug code on claim | J0717 + units (1 mg = 1 unit) | NDC only — no J0717 |
| Admin code | 96372 (therapeutic SC) by HCP | None — patient self-administers |
| Claim form | CMS-1500 / 837P (provider) or UB-04 / 837I (HOPD) | Pharmacy NCPDP |
| Insurance benefit | Commercial medical, Medicare Part B (incident-to physician), Medicaid medical | Commercial pharmacy, Medicare Part D, Medicaid pharmacy |
| Patient cost share | Medical deductible + coinsurance (often 20% Part B) | Pharmacy tier copay (often Tier 5 specialty) |
| Copay assistance applies? | UCB Cimzia Cost Coverage Support (commercial only) | Same UCB program (commercial only) |
Most common Cimzia billing error: billing J0717 under the medical benefit when the
specialty pharmacy already filled the drug under pharmacy benefit. This produces duplicate-billing denials
and recoupment risk. Confirm the dispensing pathway with the SP and the patient's plan BEFORE the
encounter.
Medicare specifics: Part B covers J0717 only when the drug is furnished and administered
incident to a physician's professional service in the office. Self-injected Cimzia at home is a Part D
drug. If the patient has Part B + Part D and the dose is given in office, bill Part B; if the patient
self-injects at home, bill Part D via specialty pharmacy.
Dosing & unit math FDA label revised 2025
From the FDA prescribing information; six adult indications across rheumatology, dermatology, and gastroenterology.
Rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), non-radiographic axial spondyloarthritis (nr-axSpA)
- Loading: 400 mg SC (given as 2 × 200 mg injections at separate sites) at weeks 0, 2, and 4
- Maintenance: 400 mg q4wk SC OR 200 mg q2wk SC
- 1 mg = 1 unit → 400 units per loading dose; 200 or 400 units per maintenance dose
- For RA: may be given as monotherapy or in combination with methotrexate
Plaque psoriasis (PsO)
- Standard: 400 mg SC every 2 weeks (no separate loading; the q2wk schedule applies from week 0)
- Body weight ≤90 kg: consider 400 mg SC at weeks 0, 2, and 4 then 200 mg q2wk SC
- 1 mg = 1 unit → 200 or 400 units per dose
Crohn's disease (adult, after inadequate response to conventional therapy)
- Loading: 400 mg SC at weeks 0, 2, and 4
- Maintenance: 400 mg q4wk SC if clinical response is achieved
- 1 mg = 1 unit → 400 units per dose
- Pediatric Crohn's is NOT an approved indication for Cimzia in the US
Worked example — first-year billing for an RA patient on 200 mg q2wk maintenance
# Loading: 400 mg at weeks 0, 2, 4 (3 doses)
Units per loading dose: 400 (J0717)
Loading total units (3 × 400): 1,200
# Maintenance: 200 mg q2wk starting week 6 (~24 doses in remaining weeks of year 1)
Units per maintenance dose: 200
Maintenance total units (24 × 200): 4,800
# Year-1 totals
Total doses: 27 · Total units: 6,000
Total drug cost (Q2 2026 ASP+6%): ~$22,740 before sequestration
Admin code: 96372 per encounter when office-administered · Modifier: JZ
Units per loading dose: 400 (J0717)
Loading total units (3 × 400): 1,200
# Maintenance: 200 mg q2wk starting week 6 (~24 doses in remaining weeks of year 1)
Units per maintenance dose: 200
Maintenance total units (24 × 200): 4,800
# Year-1 totals
Total doses: 27 · Total units: 6,000
Total drug cost (Q2 2026 ASP+6%): ~$22,740 before sequestration
Admin code: 96372 per encounter when office-administered · Modifier: JZ
No premedication routinely required
Unlike infused biologics (Remicade, Tysabri, Ocrevus), Cimzia does not require pre-administration steroid or antihistamine premedication. Manage injection-site reactions or the rare hypersensitivity reaction per FDA label.
Presentations & NDC FDA NDC Directory verified May 2026
| Presentation | NDC (10-digit) | Notes |
|---|---|---|
| 200 mg/mL single-dose prefilled syringe (Starter Kit, 2 × 200 mg) | 50474-700-79 |
Standard for self-injection and office administration; ready-to-use, no reconstitution |
| 200 mg lyophilized powder single-dose vial (kit with diluent) | 50474-710-62 |
Requires reconstitution with sterile water for injection; primarily HCP-administered |
| 200 mg/mL prefilled e-Device (UCB AutoClicks / SmartJect) | Verify on UCB CIMplicity | Patient-friendly device for self-injection; ergonomic alternative to syringe |
Use carton-level NDC, not vial- or syringe-level when payer expects 11-digit format.
Convert 10-digit to 11-digit by inserting the leading zero in the segment with 4 digits (e.g.,
50474-700-79 → 50474-0700-79). Use N4 qualifier on CMS-1500 24A shaded
area.
HCPCS J0717 excludes biosimilars. As of May 2026, no biosimilar to certolizumab pegol
has been FDA-approved in the US. Any future biosimilar would receive its own permanent Q-code, not bill
under J0717.
Phase 2
Code the claim
SC injection means CPT 96372 — not 96365 or 96413. Get this right or claim denies.
Administration codes CPT verified May 2026
Cimzia is a SUBCUTANEOUS injection — the admin code reflects that. Do NOT bill IV admin codes.
| Code | Description | When to use |
|---|---|---|
96372 |
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | Primary code for office-administered Cimzia. Standard non-chemo SC therapeutic admin code for anti-TNF biologics. |
96401 |
Chemotherapy administration, SC/IM; non-hormonal anti-neoplastic | Some payers accept 96401 for biologic SC administration. Cimzia is non-oncologic; check payer policy. 96372 is the safer default. |
96365 / 96366 |
Therapeutic IV infusion (non-chemo) | NOT appropriate. Cimzia is NEVER given IV. Billing 96365 will trigger denial and audit risk. |
96413 / 96415 |
Chemotherapy IV infusion | NOT appropriate. Cimzia is SC, not IV, and is not classified as chemotherapy admin. |
Two injections, one encounter: the 400 mg dose is administered as 2 × 200 mg
injections at separate anatomic sites. Most payers reimburse 96372 once per encounter regardless of the
number of injections given of the same drug. Check payer policy before billing 96372 × 2 —
some payers explicitly disallow it for the same drug at the same encounter.
Why SC therapeutic admin (96372), not chemo admin (96401): Cimzia is a non-oncologic
biologic. CPT chemo admin codes 96401–96425 apply to anti-neoplastic and certain immunotherapy
agents. For anti-TNF biologics like Cimzia, Humira, Enbrel, and Simponi, 96372 is the standard SC
therapeutic admin code. Some commercial payers historically accepted 96401 for biologic SC; verify per
payer.
Patient self-injection at home: no admin code is billed. The drug is dispensed via
specialty pharmacy under pharmacy benefit. Do not submit J0717 or 96372 if the patient self-injects.
Modifiers CMS verified May 2026
JZ — required on virtually every medical-benefit claim
Effective July 1, 2023, CMS requires the JZ modifier on all single-dose container claims when no drug is discarded. Cimzia 200 mg/mL prefilled syringes and 200 mg lyophilized vials are both single-dose containers. The 200 mg dose uses one syringe with zero waste; the 400 mg dose uses two syringes with zero waste. JZ applies to virtually every J0717 medical-benefit claim.
JW — rarely applies with prefilled syringes
JW reports the discarded portion of a single-dose container. Because Cimzia syringes are pre-measured at 200 mg and the labeled doses (200 or 400 mg) are exact multiples, partial-vial waste is uncommon. JW may apply only if a clinician draws a partial dose from the lyophilized-vial preparation and discards the remainder. One of JZ or JW must be on every J0717 claim under medical benefit.
Modifier 25 — same-day E/M
Use modifier 25 on the E/M code when a significant, separately identifiable evaluation and management service is performed on the same day as the injection. Routine pre-injection clinical assessment is bundled into 96372.
340B modifiers (JG, TB)
For 340B-acquired Cimzia administered under medical benefit, follow your MAC's current 340B modifier policy. Self-injected pharmacy-benefit dispensing is not subject to 340B medical claim modifiers.
ICD-10-CM by indication FY2026 verified May 2026
Six FDA-approved adult indications. Use the most specific code supported by encounter documentation.
| Indication | ICD-10 family | Notes |
|---|---|---|
| Rheumatoid arthritis (seropositive / seronegative) | M05.x (seropositive) / M06.x (other) | Most common Cimzia indication; payer step therapy from MTX/csDMARD typical |
| Psoriatic arthritis | L40.5x (arthropathic psoriasis) / M07.x (psoriatic and enteropathic arthropathies) | Combined dermatologic + joint disease |
| Ankylosing spondylitis | M45.x | Specify region (cervical, thoracic, lumbar, etc.) |
| Non-radiographic axial spondyloarthritis (nr-axSpA) | M46.8 (other specified inflammatory spondylopathies) or per payer policy | Requires objective signs of inflammation (elevated CRP or MRI findings); document carefully |
| Plaque psoriasis (moderate-to-severe) | L40.0 (psoriasis vulgaris) / L40.x per subtype | BSA ≥10% or PASI/DLQI thresholds typical for PA |
| Crohn's disease (adult, after conventional therapy) | K50.x (specify location: small intestine K50.0x, large intestine K50.1x, both K50.8x, unspecified K50.9x; with/without complications) | Pediatric Crohn's NOT an approved indication; do not use K50.x for pediatric patients on Cimzia PA |
Indication-specific PA criteria are universal. All major payers require ICD-10 code,
prior conventional therapy documentation (e.g., MTX failure for RA, 5-ASA/steroid for Crohn's, topicals
and phototherapy for PsO), and often step therapy through preferred TNFi (Humira/Enbrel) before
approving Cimzia. The ICD-10 code alone is not sufficient.
Site of care & place of service Verified May 2026
Most commercial Cimzia volume is patient self-injection at home under pharmacy benefit. Office administration accounts for the medical-benefit J0717 claim volume and is subject to standard site-of-care UM for biologics.
| Setting | POS | Claim form | Benefit / payer steering |
|---|---|---|---|
| Patient home (self-injection) | n/a | Pharmacy NCPDP | Most common pathway. Pharmacy benefit; SP-dispensed |
| Physician office (rheumatology, derm, GI) | 11 | CMS-1500 / 837P | Medical benefit; preferred by commercial UM when office-administered |
| Ambulatory infusion suite | 49 | CMS-1500 / 837P | Acceptable; less common for SC-only drugs |
| Hospital outpatient (on-campus) | 22 | UB-04 / 837I | Disfavored; commercial site-of-care UM steers SC biologics out of HOPD |
| Hospital outpatient (off-campus PBD) | 19 | UB-04 / 837I | Disfavored |
Why office or home wins for Cimzia: SC injection takes seconds and requires no infusion
chair, no nursing supervision beyond the injection itself, and no observation period. Commercial payers
will not authorize HOPD administration of an SC biologic in nearly all cases.
Claim form field mapping (medical benefit) UCB CIMplicity 2026
For office-administered Cimzia under the medical benefit. Pharmacy-benefit self-injection uses NCPDP, not CMS-1500.
| Information | CMS-1500 box | Notes |
|---|---|---|
| NPI | 17b | Rendering provider |
| NDC qualifier + 11-digit NDC + UoM + qty | 24A shaded area | N4 + carton NDC + ML + total volume (1 mL for 200 mg, 2 mL for 400 mg) |
| HCPCS J0717 + JZ (or JW if waste) | 24D (drug line) | JZ on virtually every claim — single-dose syringe, no waste |
| Drug units | 24G | 200 (200 mg dose) or 400 (400 mg dose) |
| CPT 96372 (admin line) | 24D (admin line) | Therapeutic SC, non-chemo |
| ICD-10 | 21 | Indication-specific (see ICD-10 table) |
| PA number | 23 | Required by all major commercial payers |
| TB screening documentation | chart | Maintain in chart for audit; payers may request copy as part of PA |
Phase 3
Get paid
PA is universal. Step therapy from preferred TNFi is the most common approval barrier.
Payer policy snapshot + step therapy Reviewed May 2026
All major commercial payers require PA. Step therapy through Humira or Enbrel is common; the pregnancy use case can drive an exception.
| Payer | PA? | Step therapy | Notes |
|---|---|---|---|
| UnitedHealthcare Pharmacy & medical drug policies |
Yes | Step from preferred TNFi (Humira / Enbrel) typical for RA, PsA, PsO, AS | Pregnancy / planning pregnancy is recognized exception; Crohn's typically step from infliximab or adalimumab |
| Aetna CPB + Medical Drug policies |
Yes | Step therapy varies by plan; many plans require failure of one preferred TNFi | Aetna recognizes pregnancy exception; nr-axSpA requires objective inflammation documentation |
| BCBS plans Vary by plan |
Yes | Step therapy in most commercial plans; Federal Employee Program follows tiered formulary | Some BCBS plans now require biosimilar adalimumab trial first |
| Cigna / Express Scripts Accredo SP-aligned |
Yes | Step therapy through Humira biosimilar typical | SP-dispensed under pharmacy benefit |
| Medicare Part B when office-administered |
No (FFS); MA plans may require | None at FFS | Medicare Advantage plans frequently apply commercial-style PA + step |
| Medicare Part D when self-injected |
Yes (formulary tier) | Tier 5 specialty typical; PA per plan | Patient OOP is often substantial; refer to copay assistance pathways below |
Pre-treatment screening required by all payers (and the FDA label)
- TB screening (PPD or IGRA) — baseline before initiation, with treatment of latent TB infection (LTBI) prior to or concurrent with Cimzia start
- Hepatitis B serology — risk of HBV reactivation in chronic carriers
- Vaccination status review — live vaccines should be brought up to date BEFORE starting Cimzia (no live vaccines while on therapy)
- Heart failure screening — TNFi caution in NYHA III/IV CHF
- Demyelinating disease history — TNFi caution in MS or optic neuritis history
TB screening is non-negotiable. Document PPD or IGRA result, date, and any LTBI
treatment in the chart and PA submission. Payers commonly request this documentation; missing TB
screening is a frequent cause of PA denials and downstream audit findings.
Medicare reimbursement CMS Q2 2026 (live)
Quarterly ASP from CMS Part B Drug Pricing File. Refreshes automatically each quarter. Applies only when J0717 is billed (office-administered, Part B).
Q2 2026 payment snapshot — J0717
Effective April 1 – June 30, 2026 · Based on 4Q25 ASP submissions
ASP + 6%
$3.790
per mg / per unit
200 mg dose (q2wk)
$758.00
200 units × ASP+6%
400 mg dose (loading or q4wk)
$1,516.00
400 units × ASP+6%
Annualized cost (medical benefit, ASP+6%): 200 mg q2wk × 26 doses + 3
loading doses (400 mg) = ~$5,548 (loading) + ~$19,708 (maintenance) = ~$25,256 year-1;
steady-state ~$19,708/year. 400 mg q4wk × 13 doses + 3 loading = same total drug volume.
After ~2% sequestration, actual paid is roughly ASP + 4.3%.
Coverage
No NCD specific to certolizumab pegol. Coverage falls under MAC LCDs for biologics + the generic drug-coverage framework. All MACs cover J0717 for FDA-approved on-label indications when administered incident-to a physician's service with appropriate ICD-10 documentation.
Code history
- J0717 — permanent code, "Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)" — reflects the medical-benefit-only nature of J0717
- Prior to permanent code: billed under unclassified J3490 / J3590
Patient assistance — UCB CIMplicity UCB verified May 2026
- UCB CIMplicity: 1-844-246-9425 (1-844-2-CIMZIA) / cimzia.com — benefits investigation, PA support, appeal assistance, nurse support
- Cimzia Cost Coverage Support (commercial copay program): eligible commercially-insured patients may pay as little as $0 per dose, up to $20,000/year; excludes Medicare, Medicaid, TRICARE, VA, and other federal program patients
- Cimzia Patient Assistance Program: free drug for uninsured / underinsured patients meeting income requirements; administered through UCB's PAP
- Bridge program: short-term free drug while PA is in process for commercially-insured patients with documented coverage
- Foundations (for Medicare patients): refer to PAN Foundation, HealthWell Foundation — verify open RA / PsA / Crohn's / PsO funds quarterly
Need to model what a specific patient will actually pay after copay assistance, deductible, coinsurance,
and OOP max? Run a CareCost Estimate — J0717 pre-loaded.
Phase 4
Fix problems
Wrong admin code (96365 instead of 96372), missing TB documentation, and benefit-pathway mix-ups are the top three.
Common denials & how to fix them
| Denial reason | Common cause | Fix |
|---|---|---|
| Wrong admin code (96365 / 96413) | IV admin code billed for SC injection | Resubmit with 96372. Cimzia is SC, never IV. Update biller education. |
| Duplicate billing (medical + pharmacy) | J0717 billed under medical benefit when SP already filled it under pharmacy benefit | Verify dispensing pathway with SP and patient's plan BEFORE encounter. Reverse the duplicate claim and bill only the appropriate pathway. |
| Missing TB screening documentation | PA submitted without PPD/IGRA result | Submit PPD or IGRA result + LTBI treatment plan if positive. Required by FDA label and every payer policy. |
| Step therapy not met | Cimzia requested before trial of preferred TNFi (Humira / Enbrel / biosimilar) | Document failure / intolerance / contraindication to preferred TNFi. Pregnancy or planning pregnancy is a recognized exception — cite the Fc-free clinical advantage. |
| JZ missing on adult claim | Single-dose syringe claim without JZ | Resubmit with JZ. Required since 7/1/2023 on every J0717 medical-benefit claim with no waste. |
| Wrong NDC format | 10-digit NDC submitted when payer requires 11-digit | Convert to 11-digit (e.g., 50474-700-79 → 50474-0700-79). Use N4 qualifier. |
| Site of care (HOPD) | HOPD administration of an SC biologic | Move to office (POS 11) or to home self-injection via pharmacy benefit. Commercial payers will not authorize HOPD for SC biologics in most cases. |
| nr-axSpA without objective inflammation | PA submitted without elevated CRP or MRI findings | Document either elevated CRP or MRI evidence of active inflammation; required by FDA label and PA criteria. |
| Pediatric Crohn's PA | Cimzia requested for pediatric Crohn's patient | Pediatric Crohn's is NOT an FDA-approved Cimzia indication. Use alternative TNFi with pediatric Crohn's labeling (e.g., infliximab, adalimumab). |
| Self-injection billed as medical benefit | J0717 + 96372 submitted when patient self-injected at home | Reverse claim. Self-injection is pharmacy benefit only; no medical-benefit claim is appropriate. |
Frequently asked questions
What is the HCPCS code for Cimzia?
Cimzia (certolizumab pegol) is billed under HCPCS J0717 — "Injection, certolizumab
pegol, 1 mg." Each milligram equals one billable unit. The standard 400 mg loading dose (weeks 0, 2, 4)
is billed as 400 units; 200 mg q2wk maintenance is billed as 200 units; 400 mg q4wk maintenance is
billed as 400 units.
Is Cimzia billed under medical or pharmacy benefit?
It depends on where it is administered. When administered in a physician office, infusion suite, or
clinic and the provider buys-and-bills, Cimzia is billed under the MEDICAL benefit
using HCPCS J0717. When the patient self-injects at home from a specialty pharmacy fill,
it is billed under the PHARMACY benefit using NDC, not J0717. Many commercial payers
and Medicare Part D plans push Cimzia to pharmacy benefit; Medicare Part B covers J0717 only when
furnished and administered incident-to a physician's service. Always verify benefit pathway before
submitting the claim.
What administration CPT do I use for Cimzia?
When administered in office, use CPT 96372 — "Therapeutic, prophylactic, or
diagnostic injection (specify substance or drug); subcutaneous or intramuscular." Cimzia is a
SUBCUTANEOUS injection — NOT IV — so do NOT bill 96365 (therapeutic IV) or 96413 (chemo
IV). Some payers accept 96401 (chemo SC) for biologic SC, but 96372 is the standard non-chemo SC code
for anti-TNF biologics.
Do I bill JZ or JW for Cimzia?
Bill JZ on Cimzia claims when administered from a single-dose prefilled syringe or
single-dose vial with no waste — the standard scenario. The 400 mg dose uses two 200 mg syringes
with zero waste. JW only applies if a partial dose is drawn and the remainder discarded
(uncommon with prefilled syringes). One of JZ or JW must be on every J0717 claim under medical benefit
per CMS's July 2023 single-dose container policy.
What is the Medicare reimbursement for J0717?
For Q2 2026, the Medicare Part B payment limit for J0717 is $3.790 per mg (ASP + 6%). The 400 mg loading dose reimburses at approximately $1,516.00; the 200 mg q2wk maintenance dose at approximately $758.00; the 400 mg q4wk maintenance dose at approximately $1,516.00. Annualized cost (Medicare ASP+6%) maintenance ~$19,708. Sequestration (~2%) reduces actual paid to roughly ASP + 4.3%.
What indications is Cimzia approved for?
Cimzia is FDA-approved for six adult indications: (1) moderately to severely active rheumatoid arthritis (RA), (2) active psoriatic arthritis (PsA), (3) active ankylosing spondylitis (AS), (4) active non-radiographic axial spondyloarthritis (nr-axSpA) with objective signs of inflammation, (5) moderate-to-severe plaque psoriasis (PsO), and (6) moderate-to-severe Crohn's disease in adults with inadequate response to conventional therapy. Pediatric Crohn's and pediatric uveitis are NOT approved indications.
Why is Cimzia often preferred over other TNFi in pregnancy?
Cimzia is a PEGylated humanized antibody Fab′ fragment — it lacks an Fc region. Placental transfer of antibodies is mediated by the FcRn receptor binding to the Fc portion of IgG. Without an Fc, certolizumab pegol shows minimal active placental transfer (CRIB study: median infant cord blood concentration <0.41 µg/mL vs maternal 24 µg/mL at delivery). For patients requiring TNFi during pregnancy, Cimzia is often preferred over Humira, Enbrel, Remicade, and Simponi — all of which are full IgG with active placental transfer in the third trimester. ACR, EULAR, and the AGA pregnancy in IBD guideline all reflect this.
What is the boxed warning for Cimzia?
Cimzia carries a class-wide TNF blocker boxed warning with two components: (1) SERIOUS INFECTIONS — increased risk including active TB (often disseminated or extrapulmonary, including reactivation of latent TB), invasive fungal infections (histoplasmosis, coccidioidomycosis, candidiasis, aspergillosis, blastomycosis, pneumocystosis), and bacterial, viral, and other opportunistic pathogens; mandatory pre-treatment TB screening (PPD or IGRA) and hepatitis B screening required. (2) MALIGNANCIES — lymphoma and other malignancies, some fatal, in children and adolescents treated with TNF blockers; postmarketing reports of hepatosplenic T-cell lymphoma (HSTCL) primarily in adolescent and young adult males with IBD treated with TNFi plus thiopurines (azathioprine, 6-MP). Discontinue Cimzia if the patient develops a serious infection or sepsis.
Reference
Sources & methodology
Every claim on this page is sourced. Methodology and review history below.
Source documents
- UCB Cimzia HCP and patient site
- DailyMed — CIMZIA (certolizumab pegol) Prescribing Information
- FDA Cimzia label PDF (Drugs@FDA)
- CMS — Medicare Part B Drug ASP Pricing File
- CMS HCPCS Level II quarterly file — J0717 descriptor
- UCB CIMplicity patient & HCP support program
- UnitedHealthcare medical and pharmacy drug policies (TNFi class)
- Aetna CPB — TNF-alpha inhibitors (Cimzia covered)
- ACR clinical practice guidelines — RA, PsA, AS
- AGA — pregnancy in IBD guidance
- CRIB study — Mariette et al., Ann Rheum Dis 2018 (placental transfer of certolizumab pegol)
- FDA National Drug Code Directory
About this page
We maintain this page as a living reference. Medicare ASP pricing is bound to our underlying CareCost data layer and refreshes automatically when CMS publishes new quarterly files. Coding and policy content is reviewed at least quarterly and updated whenever a source document changes.
Found an error? Email hello@carecostestimate.com.
Refresh cadence
| Element | Cadence | How it's refreshed |
|---|---|---|
| Medicare ASP pricing | Quarterly | Auto-bound to CareCost ASP layer; updates on CMS file release. |
| Payer policies (UHC, Aetna, BCBS, Cigna) | Semi-annual | Manual review against published payer policy documents. |
| HCPCS / CPT / modifier rules | Annual | Reviewed against CMS HCPCS quarterly files and AMA CPT releases. |
| NDC, dosing, FDA label, indication list | Event-driven | Tied to UCB document version + FDA label revision date. |
| UCB CIMplicity benefits + copay program details | Annual | Verified against UCB's published HCP and patient resources. |
Reviewer
Pending SME review. This page is staff-authored from primary sources (FDA, CMS, UCB,
payer documents, ACR/EULAR/AGA guidelines — all linked above). Editorial review in progress. Until that review is complete, treat this as a draft reference and verify
each cited source for high-stakes claims.
Change log
- — Initial publication. ASP data: Q2 2026 ($3.790/mg). Manufacturer source: UCB CIMplicity 2026. FDA label: 2025 revision. Six FDA-approved adult indications (RA, PsA, AS, nr-axSpA, plaque PsO, Crohn's). Medical vs pharmacy benefit pathway disambiguation called out as primary billing decision.
Methodology
Every claim on this page is sourced inline. Pricing reflects the current CMS Part B Drug ASP Pricing File. Payer policies are read directly from each payer's published medical/pharmacy policy documents. Indication list is verified against the current FDA label revision. We do not paraphrase from billing-software vendor blogs.