Golimumab

This policy addresses coverage of golimumab (Simponi/Simponi Aria) for inflammatory arthritides—including moderately to severely active rheumatoid arthritis in adults (when used with methotrexate), active psoriatic arthritis and polyarticular juvenile idiopathic arthritis in patients ≥2 years, and active ankylosing spondylitis in adults. Coverage requires dosing/frequency/duration consistent with authoritative sources (or FDA/compendia), off‑label uses must be supported by two peer‑reviewed articles, and major limitations include prohibition of concomitant TNF or IL‑1 antagonists, possible exclusion of prior TNF‑exposed patients, management of self‑administered formulations under the pharmacy benefit, and dependence on the member’s benefit plan/contract.

"Requested therapy must be proven effective for the relevant diagnosis or procedure."

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