J1602, Injection, golimumab, 1 mg, for intravenous use
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Documented diagnosis appropriate to the indication (e.g., active ankylosing spondylitis, active psoriatic arthritis, moderately to severely active rheumatoid arthritis, moderately to severely active polyarticular juvenile idiopathic arthritis).
- For initial AS medical necessity: documentation of failure to two NSAIDs at maximally indicated doses, each used for at least 4 weeks, unless contraindicated or adverse effects; or documentation of prior treatment with a targeted immunomodulator FDA-approved for AS; or documentation patient is currently on Simponi Aria.
- For initial PsA medical necessity: documentation of failure of a 3-month trial of methotrexate at the maximally indicated dose unless contraindicated or adverse effects; or documentation of prior treatment with a targeted immunomodulator FDA-approved for PsA; or documentation patient is currently on Simponi Aria.
- For initial RA medical necessity: documentation of concurrent methotrexate therapy OR history of intolerance/failure to a 3-month trial of one non-biologic DMARD at maximally indicated doses (unless contraindicated), OR prior targeted immunomodulator use, OR documentation patient is currently on Simponi Aria.
- For pJIA: documentation of moderately to severely active polyarticular juvenile idiopathic arthritis and that dosing will follow FDA labeled dosing for pJIA.
- For continuation requests for any indication: documentation that the patient has previously received Simponi Aria IV and documentation of positive clinical response to Simponi Aria (clinical notes demonstrating benefit).
Key Coverage Criteria
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
- Ankylosing spondylitis (AS) — Simponi Aria is proven for the treatment of ankylosing spondylitis when criteria are met.
- Psoriatic arthritis (PsA) — Simponi Aria is proven for the treatment of psoriatic arthritis when criteria are met. (Policy and FDA: active PsA in patients 2 years of age or older.)
- Rheumatoid arthritis (RA) — Simponi Aria is proven for the treatment of moderately to severely active rheumatoid arthritis when criteria are met. (FDA: indicated for adult patients with moderately to severely active RA in combination with methotrexate.)
- Polyarticular juvenile idiopathic arthritis (pJIA / PJIA) — Simponi Aria is proven for the treatment of polyarticular juvenile idiopathic arthritis when criteria are met. (FDA: active pJIA in patients 2 years of age or older.)
- FDA-specific: Simponi Aria (IV) indicated for adult RA (in combination with methotrexate), active PsA (>=2 years), active AS, and active pJIA (>=2 years).
16 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UHC-POL-simponi-aria-golimumab-injection-intravenous-infusion, Simponi Aria (Golimumab) Injection for Intravenous Infusion
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
AETNA-CPB-0602, Intradiscal Procedures
RX501.112, Golimumab
BCBSIL-RX501.112, Golimumab
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.112, Golimumab
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.112, Golimumab
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.112, Golimumab
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UMR-POL-UMR-simponi-aria-golimumab-injection-intravenous-infusion, Simponi Aria (Golimumab) Injection for Intravenous Infusion
SUREST-POL-SUREST-simponi-aria-golimumab-injection-intravenous-infusion, Simponi Aria (Golimumab) Injection for Intravenous Infusion
Related Codes
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