Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Preferred Agents:
Axial Spondyloarthritis/Ankylosing Spondylitis (AS)
TNF Inhibitors
adalimumab-adaz
adalimumab-adbm - labeler 00597
adalimumab-fkjp
AVSOLA (infliximab-axxq)
CYLTEZO (adalimumab-abdm)
ENBREL (etanercept)
HULIO (adalimumab-fkjp)
HUMIRA (adalimumab)
RENFLEXIS (infliximab-abda)
SIMLANDI (adalimumab-ryvk)
SIMPONI (golimumab) subcutaneous
YUSIMRY (adalimumab-aqvh)
Interleukin (IL) - 17 Inhibitors
TALTZ (ixekizumab)
Janus Kinase (JAK) Inhibitor
XELJANZ IR (tofacitinib) 5mg tablet, oral solution
RINVOQ ER (upadacitinib)
Polyarticular Juvenile Idiopathic Arthritis (PJIA)
TNF Inhibitors
adalimumab-adaz
adalimumab-adbm - labeler 00597
adalimumab-fkjp
CYLTEZO (adalimumab-abdm)
ENBREL (etanercept)
HULIO (adalimumab-fkjp)
HUMIRA (adalimumab)
SIMLANDI (adalimumab-ryvk)
YUSIMRY (adalimumab-aqvh)
Janus Kinase (JAK) Inhibitor
XELJANZ IR (tofacitinib) 5mg tablet, oral solution
RINVOQ ER (upadacitinib)
T-cell Costimulation Blocker
ORENCIA (abatacept) - 125 mg/mL syringe subcutaneous
Psoriatic Arthritis (PsA)
TNF Inhibitors
adalimumab-adaz
adalimumab-adbm - labeler 00597
adalimumab-fkjp
AVSOLA (infliximab-axxq)
CYLTEZO (adalimumab-abdm)
ENBREL (etanercept)
HULIO (adalimumab-fkjp)
HUMIRA (adalimumab)
RENFLEXIS (infliximab-abda)
SIMLANDI (adalimumab-ryvk)
SIMPONI (golimumab) subcutaneous
YUSIMRY (adalimumab-aqvh)
Janus Kinase (JAK) Inhibitor
RINVOQ ER (upadacitinib)
Interleukin (IL)-23p19 Inhibitor
SKYRIZI (risankizumab-rzaa)
TREMFYA (guselkumab)
Interleukin (IL)-17 Inhibitor
TALTZ (ixekizumab)
Rheumatoid Arthritis (RA)
TNF Inhibitors
adalimumab-adaz
adalimumab-adbm - labeler 00597
adalimumab-fkjp
AVSOLA (infliximab-axxq)
CYLTEZO (adalimumab-abdm)
ENBREL (etanercept)
HULIO (adalimumab-fkjp)
HUMIRA (adalimumab)
RENFLEXIS (infliximab-abda)
SIMLANDI (adalimumab-ryvk)
SIMPONI (golimumab) subcutaneous
YUSIMRY (adalimumab-aqvh)
Janus Kinase (JAK) Inhibitor
XELJANZ (tofacitinib)
RINVOQ ER (upadacitinib)
T-cell Costimulation Blocker
ORENCIA (abatacept) - 125 mg/mL syringe subcutaneous
Interleukin (IL)-6 Inhibitor
ACTEMRA (tocilizumab)
TYENNE (tocilizumab-aazg)
The use of golimumab (Simponi Aria) may be considered medically necessary when ALL of the following criteria are met:
-
The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route);
and
-
Golimumab (Simponi Aria) must be prescribed by, or in consult with, a specialist in the area of the individual's treated diagnosis;
and
-
Clinical justification must be provided why a self-administered agent cannot be used (subject to clinical review);
and
- If diagnosis is AS, the individual must have failed a 30-day trial of Xeljanz and Rinvoq ER, and a 90-day trial of a TNF inhibitor, and a 90-day trial of Taltz, as evidenced by paid claims or pharmacy printouts.
- If diagnosis is PJIA, the individual must have failed a 3-month trial of a TNF inhibitor and Orencia, and a 30-day trial of Xeljanz, as evidenced by paid claims or pharmacy print outs
-
if diagnosis is RA, the individual must have failed a 3-month trial of each of the following, as evidenced by paid claims and pharmacy printouts:
-
TNF Inhibitor,
and
-
Orencia;
and
-
Xeljanz;
and
- tocilizumab.
-
if diagnosis PsA, the individual must have failed a 3-month trial of each of the following, as evidenced by paid claims or pharmacy printouts:
-
TNF inhibitor;
and
-
Interleukin (IL) - 17 inhibitor (TALTZ - ixekizumab) ;
and
- Janus Kinase inhibitor (Rinvoq ER or Xeljanz).
Reauthorization Criteria
The continues use of golimumab (Simponi Aria) may be considered medically necessary when
ALL
of the following criteria are met:
-
The individual has previously been approved for golimumab (Simponi Aria) through Blue Cross Blue Shield of North Dakota's precertification process;
and
-
The prescriber has provided documentation that the individual has demonstrated disease stability or beneficial response to therapy;
and
- The individual must continue to meet applicable initial criteria.
The use of golimumab (Simponi Aria) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
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