Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Preferred Agents:
Ankylosing Spondylitis (AS)
Anti-TNF Inhibitors
ENBREL (etanercept)
HUMIRA (adalimumab)
Anti–interleukin (IL) 17 Antibodies
TALTZ (ixekizumab)
Polyarticular Juvenile Idiopathic Arthritis (PJIA)
Janus Kinase (JAK) Inhibitors
XELJANZ (tofacitinib)
XELJANZ (tofacitinib) ORAL SOLUTION
XELJANZ XR (tofacitinib)
Psoriatic Arthritis (PsA)
Anti-TNF Inhibitors
ENBREL (etanercept)
HUMIRA (adalimumab)
Phosphodiesterase 4 (PDE4) Inhibitor
OTEZLA (apremilast)
Janus Kinase (JAK) Inhibitors
XELJANZ (tofacitinib)
Rheumatoid Arthritis (RA)
Anti-TNF Inhibitors
ENBREL (etanercept)
HUMIRA (adalimumab)
Janus Kinase (JAK) Inhibitors
XELJANZ (tofacitinib)
Anti-Interleukin-1 (IL-1) Receptor Inhibitors
KINERET (anakinra)
The use of golimumab (Simponi Aria) may be considered medically necessary when ALL of the following criteria are met:
- The individual must have an FDA-approved indication for use (meets label recommendations for diagnosis and age); and
- The individual must have had a 3-month trial of a preferred agent from each class approved for patient’s diagnosis, as evidenced by paid claims or pharmacy printouts.
Golimumab (Simponi Aria) for any other indication is considered experimental/investigational and therefore non-covered. Scientific evidence has not established the effectiveness for any other indication.
Procedure Codes
