ModifiedAmeriHealth Caritas VIP CarePolicy MA08.070g

Golimumab (Simponi Aria) Intravenous (IV) Injection

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Medical-benefit coverage and medical necessity criteria for intravenous Simponi Aria (golimumab) for covered inflammatory arthritis indications in Medicare Advantage members; subcutaneous Simponi and Part D pharmacy-benefit coverage are outside this policy.

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ModifiedAmeriHealth Caritas VIP CarePolicy MA08.070g

Golimumab (Simponi Aria) Intravenous (IV) Injection

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Sign up for amerihealth_caritas_vip_care Policy MA08.070g alerts

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Policy Summary

PayerAmeriHealth Caritas VIP Care

PolicyGolimumab (Simponi Aria) Intravenous (IV) Injection

Policy CodePolicy MA08.070g

Change TypeModified

Effective DateDec 15, 2025

Last ReviewSep 18, 2026

Next Review DateN/A

Key ActionSubmit documentation showing the applicable indication, required prior-treatment failures or intolerance/contraindication, age where specified, and tuberculosis screening.

SourceLink

POLICY UPDATE CHANGES

The 12/15/2025 version added ICD-10-CM code M05.A for abnormal rheumatoid factor and anti-citrullinated protein antibody with rheumatoid arthritis.

Coverage requirements were revised to require rheumatoid arthritis treatment with golimumab in combination with methotrexate or, when methotrexate is contraindicated or not tolerated, another DMARD.

The policy added the listed ICD-10 diagnosis codes for rheumatoid arthritis.

J1602HCPCS code for intravenous golimumab

5Covered initial-therapy clinical indications

18+Minimum age for revised coverage criteria

3 monthsRequired prior methotrexate trial

M05.AAdded ICD-10-CM code

Coverage Criteria and Benefit Scope

Initial therapy: Ankylosing spondylitis

Covered when all of the following are met, including one of the specified prior-treatment alternatives.

Ankylosing spondylitis

Age: Individual is at least 18 years old>=18 years
ONE of the following prior-treatment alternatives
- NSAID trial: Documentation of failure, contraindication, or intolerance to at least a 4-week trial of two NSAIDs at the maximum recommended or tolerated anti-inflammatory dose>=4 weeks
- DMARD trial: Documentation of failure, contraindication, or intolerance to at least a 3-month trial of one DMARD, such as sulfasalazine, methotrexate, or hydroxychloroquine>=3 months
Tuberculosis screening: Active or latent TB has been ruled out

Initial therapy: Immune checkpoint inhibitor-related inflammatory arthritis

Covered when all of the following are met.

Immune checkpoint inhibitor-related inflammatory arthritis

Disease severity: Management of moderate or severe immunotherapy-related inflammatory arthritis
ONE of the following treatment-response criteria
- No improvement after holding immunotherapy and treating with oral corticosteroids
- Unable to taper corticosteroids
- No response to conventional synthetic DMARDs, such as methotrexate, sulfasalazine, leflunomide, or hydroxychloroquine

Initial therapy: Polyarticular juvenile idiopathic arthritis

Covered when all of the following are met.

Polyarticular juvenile idiopathic arthritis

Age: Individual is at least 2 years old>=2 years
DMARD trial: Documentation of failure, contraindication, or intolerance to at least 2 months of one DMARD, such as methotrexate>=2 months
Tuberculosis screening: Active or latent TB has been ruled out

Initial therapy: Psoriatic arthritis

Covered when all of the following are met, including one of the specified prior-treatment alternatives.

Psoriatic arthritis

Age: Individual is at least 2 years old>=2 years
ONE of the following prior-treatment alternatives
- NSAID trial: Documentation of failure, contraindication, or intolerance to at least a 4-week trial of any NSAID at the maximum recommended or tolerated anti-inflammatory dose>=4 weeks
- DMARD trial: Documentation of failure, contraindication, or intolerance to at least a 3-month trial of one DMARD, such as methotrexate, hydroxychloroquine, leflunomide, or sulfasalazine

Initial therapy: Rheumatoid arthritis

Covered when all of the following are met, with the specified methotrexate or alternative-DMARD pathway.

Rheumatoid arthritis

Disease and age: Treatment of moderately to severely active RA in an individual who is at least 18 years old>=18 years
ONE of the following prior-treatment pathways
- Methotrexate pathway: Persistent disease despite at least 3 months of methotrexate>=3 months
- Alternative DMARD pathway: Methotrexate is contraindicated or not tolerated and the individual has completed a 3-month trial of a different DMARD, such as sulfasalazine, hydroxychloroquine, or leflunomide

Continuation therapy

Covered for continuation therapy when all of the following are met.

Individual has met the medical necessity criteria for initial therapy
There is documentation of a positive clinical response or stabilization to therapy
Examples include improvement in total active swollen and tender joint count, or improvement in pain, stiffness, or inflammation from baseline

Initial therapy for rheumatoid arthritis

Golimumab is considered medically necessary and covered for moderately to severely active rheumatoid arthritis when all of the following are met.

Initial rheumatoid arthritis coverage

Age and disease: The individual is at least 18 years old and has moderately to severely active rheumatoid arthritisAge >= 18
ONE of the following prior DMARD pathways
- Methotrexate pathway: Persistent disease despite at least three months of methotrexateMTX >= 3 months
- Alternative DMARD pathway: Methotrexate is contraindicated or not tolerated and the individual has completed a three-month trial of another DMARD

This policy addresses only Simponi Aria, the intravenous form of golimumab covered under the medical benefit when the policy’s medical necessity criteria are met. Subcutaneous Simponi is outside the scope of this policy and may be available under an applicable pharmacy benefit.

This policy does not address golimumab when it is covered under the member’s Part D pharmacy benefit. Part D coverage depends on how the drug is prescribed, dispensed, or administered and is governed separately from this medical-benefit policy.

Uses of golimumab other than the covered indications are considered experimental/investigational and are not covered unless the indication is supported as an accepted off-label use under the Company’s applicable policy for prescription drugs and biologics.

Coding and Treatment Prerequisites

HCPCS Level II CodeHCPCSCovered

J1602

Injection, golimumab, 1mg, for intravenous use

CPT Procedure Code Number(s)CPT

N/A

ICD-10 Procedure Code Number(s)ICD-10

N/A

Medically Necessary ICD-10 Diagnosis CodesICD-10Covered

L40.50	Arthropathic psoriasis, unspecified
L40.51	Distal interphalangeal psoriatic arthropathy
L40.52	Psoriatic arthritis mutilans
L40.53	Psoriatic spondylitis
L40.54	Psoriatic juvenile arthropathy
L40.59	Other psoriatic arthropathy
M05.7A	Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement
M05.8A	Other rheumatoid arthritis with rheumatoid factor of other specified site
M05.00	Felty's syndrome, unspecified site
M05.011	Felty's syndrome, right shoulder

1–10 of 14

1/2

Medically Necessary ICD-10 Diagnosis CodesICD-10Covered

M05.032	Felty's syndrome, left wrist
M05.041	Felty's syndrome, right hand
M05.042	Felty's syndrome, left hand
M05.051	Felty's syndrome, right hip
M05.052	Felty's syndrome, left hip
M05.061	Felty's syndrome, right knee
M05.062	Felty's syndrome, left knee
M05.071	Felty's syndrome, right ankle and foot
M05.072	Felty's syndrome, left ankle and foot
M05.09	Felty's syndrome, multiple sites

1–10 of 27

1/3

Medically Necessary ICD-10 Diagnosis CodesICD-10Covered

M05.211	Rheumatoid vasculitis with rheumatoid arthritis of right shoulder
M05.212	Rheumatoid vasculitis with rheumatoid arthritis of left shoulder
M05.221	Rheumatoid vasculitis with rheumatoid arthritis of right elbow
M05.222	Rheumatoid vasculitis with rheumatoid arthritis of left elbow
M05.231	Rheumatoid vasculitis with rheumatoid arthritis of right wrist
M05.232	Rheumatoid vasculitis with rheumatoid arthritis of left wrist
M05.241	Rheumatoid vasculitis with rheumatoid arthritis of right hand
M05.242	Rheumatoid vasculitis with rheumatoid arthritis of left hand
M05.251	Rheumatoid vasculitis with rheumatoid arthritis of right hip
M05.252	Rheumatoid vasculitis with rheumatoid arthritis of left hip

1–10 of 21

1/3

Medically Necessary ICD-10-CM Rheumatoid Arthritis With Systemic ManifestationsICD-10Covered

M05.032	Felty's syndrome, left wrist
M05.041	Felty's syndrome, right hand
M05.042	Felty's syndrome, left hand
M05.051	Felty's syndrome, right hip
M05.052	Felty's syndrome, left hip
M05.061	Felty's syndrome, right knee
M05.062	Felty's syndrome, left knee
M05.071	Felty's syndrome, right ankle and foot
M05.072	Felty's syndrome, left ankle and foot
M05.09	Felty's syndrome, multiple sites

1–10 of 90

1/9

Medically Necessary ICD-10-CM Rheumatoid Arthritis and Related ConditionsICD-10Covered

M05.60	Rheumatoid arthritis of unspecified site with involvement of other organs and systems
M05.611	Rheumatoid arthritis of right shoulder with involvement of other organs and systems
M05.612	Rheumatoid arthritis of left shoulder with involvement of other organs and systems
M05.621	Rheumatoid arthritis of right elbow with involvement of other organs and systems
M05.622	Rheumatoid arthritis of left elbow with involvement of other organs and systems
M05.631	Rheumatoid arthritis of right wrist with involvement of other organs and systems
M05.632	Rheumatoid arthritis of left wrist with involvement of other organs and systems
M05.641	Rheumatoid arthritis of right hand with involvement of other organs and systems
M05.642	Rheumatoid arthritis of left hand with involvement of other organs and systems
M05.651	Rheumatoid arthritis of right hip with involvement of other organs and systems

1–10 of 89

1/9

Medically Necessary ICD-10-CM Ankylosing SpondylitisICD-10Covered

M45.0	Ankylosing spondylitis of multiple sites in spine
M45.1	Ankylosing spondylitis of occipito-atlanto-axial region
M45.2	Ankylosing spondylitis of cervical region
M45.3	Ankylosing spondylitis of cervicothoracic region
M45.4	Ankylosing spondylitis of thoracic region
M45.5	Ankylosing spondylitis of thoracolumbar region
M45.6	Ankylosing spondylitis lumbar region
M45.7	Ankylosing spondylitis of lumbosacral region
M45.8	Ankylosing spondylitis sacral and sacrococcygeal region
M45.9	Ankylosing spondylitis of unspecified sites in spine

Added ICD-10 codesICD-10

M05.019
M05.029
M05.039
M05.049
M05.059
M05.069
M05.079
M05.10
M05.111
M05.112

1–10 of 93

1/10

Prior methotrexate therapy

Required therapyMethotrexate therapy is required before golimumab for rheumatoid arthritis coverage.

Minimum durationAt least 3 months.

Disease statusPersistent disease despite at least 3 months of methotrexate is required.

Alternative DMARD therapy

When applicableUse when methotrexate is contraindicated or the individual is intolerant.

Provider Documentation and Coverage Actions

Documentation Required

Initial Therapy Medical Necessity

Before requesting initial therapy, submit documentation establishing medical necessity for intravenous Simponi Aria (golimumab), including the applicable diagnosis, disease activity, age requirement, required prior-treatment failure, contraindication, or intolerance, and confirmation that active or latent tuberculosis has been ruled out.

Initial-therapy criteria vary by indication: ankylosing spondylitis, immune checkpoint inhibitor-related inflammatory arthritis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, and rheumatoid arthritis.
Document the applicable age requirement: at least 18 years for ankylosing spondylitis and rheumatoid arthritis; at least 2 years for polyarticular juvenile idiopathic arthritis and psoriatic arthritis.
Include the required prior-treatment history and the individual's response, contraindication, or intolerance.

Documentation Required

Continuation Therapy Requires Documented Response

For continuation therapy, document that the individual previously met the initial-therapy medical-necessity criteria and has demonstrated a positive clinical response or stabilization with Simponi Aria.

Clinical Background

Golimumab is a human monoclonal antibody that binds soluble and transmembrane forms of tumor necrosis factor-alpha (TNF-alpha). By preventing TNF-alpha from binding to its receptors, golimumab inhibits TNF-alpha biological activity and reduces its role in the inflammatory process.

Policy Definitions

Golimumab

Drug classHuman monoclonal antibody.

TargetBinds both soluble and transmembrane bioactive forms of human tumor necrosis factor-alpha (TNF-alpha).

MechanismPrevents TNF-alpha from binding to its receptors and inhibits the biological activity of TNF.

Simponi Aria

FormulationIntravenous formulation of golimumab.

Product nameSimponi Aria.

BenefitCovered under the medical benefit when the policy medical necessity criteria are met.

Initial Therapy by Indication

Ankylosing spondylitis initial therapy criteria

Covered for active ankylosing spondylitis when all of the following are met.

Ankylosing spondylitis

Age: Individual is at least 18 years old>=18 years
ONE of the following prior-treatment alternatives
- Documentation of failure, contraindication, or intolerance to at least a 4-week trial of two NSAIDs at the maximum recommended or tolerated anti-inflammatory dose>=4 weeks
- Documentation of failure, contraindication, or intolerance to at least a 3-month trial of one DMARD, such as sulfasalazine, methotrexate, or hydroxychloroquine

Continuation Therapy

Continuation therapy criteria

Continuation therapy is covered when all criteria are met.

Continuation criteria

Initial medical necessity criteria were met
There is documentation of a positive clinical response or stabilization to therapy
Examples include improvement in active joint count or symptoms, including pain, stiffness, or inflammation, from baseline

Prior Treatment Requirements

Indication	Required prior therapy	Duration	Failure or exception
{"text":"Ankylosing spondylitis","status":""},{"text":"Two NSAIDs at the maximum recommended or tolerated anti-inflammatory dose","status":""},{"text":"At least 4 weeks","status":""},{"text":"Failure, contraindication, or intolerance","status":""}
{"text":"Ankylosing spondylitis","status":""},{"text":"One DMARD, such as sulfasalazine, methotrexate, or hydroxychloroquine","status":""},{"text":"At least 3 months","status":""},{"text":"Failure, contraindication, or intolerance","status":""}

Indication	Required prior management	Duration or condition	Required outcome
{"text":"Immune checkpoint inhibitor-related inflammatory arthritis","status":""},{"text":"Hold immunotherapy and treat with oral corticosteroids","status":""},{"text":"Not specified","status":""},{"text":"No improvement, or inability to taper corticosteroids","status":""}
{"text":"Immune checkpoint inhibitor-related inflammatory arthritis","status":""},{"text":"Conventional synthetic DMARD, such as methotrexate, sulfasalazine, leflunomide, or hydroxychloroquine","status":""},{"text":"Not specified","status":""},{"text":"No response to treatment","status":""}

Indication	Required prior therapy	Duration	Failure or exception
{"text":"Polyarticular juvenile idiopathic arthritis","status":""},{"text":"One DMARD, such as methotrexate","status":""},{"text":"At least 2 months","status":""},{"text":"Failure, contraindication, or intolerance","status":""}

Indication	Required prior therapy	Duration	Failure or exception
{"text":"Psoriatic arthritis","status":""},{"text":"Any NSAID at the maximum recommended or tolerated anti-inflammatory dose","status":""},{"text":"At least 4 weeks","status":""},{"text":"Failure, contraindication, or intolerance","status":""}
{"text":"Psoriatic arthritis","status":""},{"text":"One DMARD, such as methotrexate, hydroxychloroquine, leflunomide, or sulfasalazine","status":""},{"text":"At least 3 months","status":""},{"text":"Failure, contraindication, or intolerance","status":""}

Indication	Required prior therapy	Duration	Failure or exception
{"text":"Rheumatoid arthritis","status":""},{"text":"Methotrexate","status":""},{"text":"At least 3 months","status":""},{"text":"Persistent disease despite therapy","status":""}
{"text":"Rheumatoid arthritis","status":""},{"text":"Different DMARD, such as sulfasalazine, hydroxychloroquine, or leflunomide","status":""},{"text":"3 months","status":""},{"text":"Use when methotrexate is contraindicated or not tolerated","status":""}

Indication	Required prior therapy	Duration	Coverage pathway
{"text":"Rheumatoid arthritis","status":""},{"text":"Methotrexate before golimumab","status":""},{"text":"At least 3 months","status":""},{"text":"Persistent disease despite methotrexate; golimumab is used in combination with methotrexate","status":""}
{"text":"Rheumatoid arthritis","status":""},{"text":"Another DMARD, such as sulfasalazine, hydroxychloroquine, or leflunomide","status":""},{"text":"3-month trial","status":""},{"text":"Alternative when methotrexate is contraindicated or not tolerated; golimumab is used with the alternative DMARD","status":""}

Administration Setting

Billing Rule

Confirm IV administration and site of care

The policy covers golimumab administered by intravenous injection. The cited policy excerpt does not state a specific administration setting; verify applicable site-of-care and reimbursement requirements before scheduling administration.

Use the intravenous Simponi Aria formulation covered under the medical benefit when the medical-necessity criteria are met.

Policy Summary

PayerAmeriHealth Caritas VIP Care

PolicyGolimumab (Simponi Aria) Intravenous (IV) Injection

Policy CodePolicy MA08.070g

Change TypeModified

Effective DateDec 15, 2025

Last ReviewSep 18, 2026

Next Review DateN/A

Key ActionSubmit documentation showing the applicable indication, required prior-treatment failures or intolerance/contraindication, age where specified, and tuberculosis screening.

SourceLink

On This Page

Tuberculosis screening: Active or latent TB has been ruled out

Alternative DMARD trial = 3 months

Examples include sulfasalazine, hydroxychloroquine, and leflunomide

Required trialA 3-month trial of a different disease-modifying antirheumatic drug is acceptable.

ExamplesSulfasalazine, hydroxychloroquine, and leflunomide.

Examples of response include improvement from baseline in total active swollen and tender joint count or improvement in pain, stiffness, or inflammation.

Step Therapy

RA Prior DMARD Therapy Required

For rheumatoid arthritis, document treatment of moderately to severely active disease in an individual at least 18 years old who has persistent disease despite the required prior DMARD therapy.

The revised requirement permits a 3-month trial of methotrexate (MTX).
When MTX is contraindicated or not tolerated, document a 3-month trial of an alternative DMARD, such as sulfasalazine, hydroxychloroquine, or leflunomide.
Simponi Aria is used in combination with MTX or an appropriate alternative DMARD.

Step Therapy

AS NSAID or DMARD Trial

For active ankylosing spondylitis, document failure, contraindication, or intolerance to either two NSAIDs or one DMARD, and document that active or latent tuberculosis has been ruled out.

Two NSAIDs: at least a 4-week trial of each at the maximum recommended or tolerated anti-inflammatory dose.
One DMARD: at least a 3-month trial, such as sulfasalazine, methotrexate, or hydroxychloroquine.

Step Therapy

pJIA DMARD Trial

For active polyarticular juvenile idiopathic arthritis, document that the individual is at least 2 years old and has failed, or has a contraindication or intolerance to, at least 2 months of one DMARD, such as methotrexate. Confirm that active or latent tuberculosis has been ruled out.

Step Therapy

RA Methotrexate or Alternative DMARD

For moderately to severely active rheumatoid arthritis, document persistent disease despite at least 3 months of methotrexate. If methotrexate is contraindicated or not tolerated, document a 3-month trial of an alternative DMARD, such as sulfasalazine, hydroxychloroquine, or leflunomide.

The individual must be at least 18 years old.
Confirm that active or latent tuberculosis has been ruled out.
Document that Simponi Aria is administered in combination with methotrexate or the accepted alternative DMARD.

Step Therapy

Checkpoint Inhibitor-Related Arthritis Treatment Failure

For moderate or severe immune checkpoint inhibitor-related inflammatory arthritis, document inadequate improvement after holding immunotherapy and treating with oral corticosteroids, inability to taper corticosteroids, or lack of response to a conventional synthetic DMARD.

Accepted conventional synthetic DMARD examples include methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine.
Confirm that active or latent tuberculosis has been ruled out.

Step Therapy

Methotrexate or Alternative DMARD Trial

When methotrexate is contraindicated or not tolerated, document the required trial of an alternative DMARD before requesting Simponi Aria for rheumatoid arthritis.

Document a 3-month trial of an alternative DMARD, such as sulfasalazine, hydroxychloroquine, or leflunomide.
Include the reason methotrexate could not be used and the alternative DMARD's treatment dates and outcome.

Documentation Required

Medical Necessity Records

Maintain records that substantiate the medical necessity of the care provided and make them available to the Company upon request.

Relevant records may include professional provider office records, hospital records, nursing-home records, home-health records, therapy records, and test reports.
The Company may review or audit services regardless of provider participation status.
Failure to produce requested documentation may result in denial of the drug.

Billing Rule

Accurate Billing Codes and Modifiers

Use the billing codes and modifiers that most accurately describe the services, devices, and pharmaceuticals rendered, unless the Company directs otherwise.

Coding-table inclusion does not guarantee reimbursement.
Eligibility, benefits, limitations, exclusions, precertification or referral requirements, provider contracts, and Company policies still apply.
Review applicable CPT, ICD-10, and HCPCS coding updates.

Documentation Required

Clinical and Prior-Treatment Documentation

For revised rheumatoid arthritis criteria, submit both clinical documentation and prior-treatment documentation supporting the request.

Document moderately to severely active RA, persistent disease despite the required prior therapy, and the individual's age.
Include MTX treatment history or, when applicable, the contraindication or intolerance and 3-month alternative-DMARD trial.
Document the combination therapy plan and tuberculosis screening.

Denial Risk

Unsupported Indication Denial Risk

Requests for uses not addressed as medically necessary are at risk for denial as experimental or investigational.

Other uses of Simponi Aria are not covered unless the indication is supported as an accepted off-label use under the Company's policy for off-label coverage of prescription drugs and biologics.

Denial Risk

Missing Records May Result in Denial

Missing or incomplete medical records may result in denial for the drug, particularly when the records do not establish medical necessity or are not produced during review or audit.

Ensure requested records are complete, legible, and available to the Company.
Include diagnosis, disease activity, age, prior-treatment history, treatment response, contraindications or intolerances, and required test reports.

Denial Risk

Verify Formulation and Benefit Pathway

This policy applies only to intravenous Simponi Aria (golimumab) covered under the medical benefit, generally the Medicare Advantage Part B benefit pathway. It does not address subcutaneous Simponi or instances covered under the pharmacy Part D benefit.

Verify that the requested product is the intravenous Simponi Aria formulation.
Confirm whether the claim belongs under the medical benefit rather than the pharmacy benefit.

Billing Rule

Verify Eligibility, Benefits, and Authorization

Before providing therapy, verify member eligibility, applicable benefits, authorization and precertification requirements, exclusions, provider-contract terms, and reimbursement rules.

Coverage is subject to the applicable Evidence of Coverage and the policy's medical-necessity criteria.
Coding-table inclusion alone does not imply reimbursement.

Denial Risk

Age and Treatment Prerequisites

Failure to meet the applicable age requirement or prior-treatment prerequisite may result in denial.

Age requirements range from at least 2 years for pJIA and PsA to at least 18 years for AS and RA.
Document the applicable NSAID, DMARD, methotrexate, corticosteroid, or immunotherapy-related treatment prerequisite before requesting initial therapy.

Outside this policySubcutaneous Simponi and pharmacy-benefit coverage are not addressed by this policy.

Polyarticular juvenile idiopathic arthritis

Disease categorySubset of juvenile idiopathic arthritis.

Joint involvementFive or more joints are affected.

TimingThe five or more joints are affected during the first 6 months after disease onset.

AbbreviationpJIA.

Psoriatic arthritis

Disease typeInflammatory arthritis.

AssociationAssociated with psoriasis.

Typical symptomsCharacterized by pain and stiffness in the affected joints.

AbbreviationPsA.

Rheumatoid arthritis

Disease typeChronic systemic autoimmune inflammatory disorder.

Primary effectsAffects joints and potentially other tissues and organs.

Common manifestationsMay cause pain, stiffness, swelling, and limited motion and function of many joints.

AbbreviationRA.

ACR response criteria

ACR2020% improvement response.

ACR5050% improvement response.

ACR7070% improvement response.

AssessmentResponses are assessed using rheumatoid arthritis disease activity criteria, including three of five criteria: acute phase reactant, patient assessment, physician assessment, pain scale, and disability/functional questionnaire.

DMARD

Full termDisease-modifying antirheumatic drug.

PurposeA treatment category used in the policy for rheumatoid arthritis and other inflammatory arthritic conditions.

ExamplesSulfasalazine, hydroxychloroquine, and leflunomide.

Alternative pathwayA different DMARD may be used when methotrexate is contraindicated or the individual is intolerant.

MTX

AbbreviationMTX.

Full termMethotrexate.

Coverage roleFor rheumatoid arthritis, golimumab is used in combination with methotrexate when the individual has persistent disease despite at least three months of methotrexate.

Tuberculosis screening: Active or latent TB has been ruled out

Immune checkpoint inhibitor-related toxicities and inflammatory arthritis criteria

Covered for moderate or severe immunotherapy-related inflammatory arthritis when all of the following are met.

Immune checkpoint inhibitor-related inflammatory arthritis

Management of moderate or severe immunotherapy-related inflammatory arthritis
ONE of the following treatment-response criteria
- No improvement after holding immunotherapy and treating with oral corticosteroids
- Unable to taper corticosteroids
- No response to conventional synthetic DMARDs, such as methotrexate, sulfasalazine, leflunomide, or hydroxychloroquine
Tuberculosis screening: Active or latent TB has been ruled out

Polyarticular juvenile idiopathic arthritis initial therapy criteria

Covered for active pJIA when all of the following are met.

Polyarticular juvenile idiopathic arthritis

Age: Individual is at least 2 years old>=2 years
DMARD trial: Documentation of failure, contraindication, or intolerance to at least 2 months of one DMARD, such as methotrexate>=2 months
Tuberculosis screening: Active or latent TB has been ruled out

Psoriatic arthritis initial therapy criteria

Covered for active PsA when all of the following are met.

Psoriatic arthritis

Age: Individual is at least 2 years old>=2 years
ONE of the following prior-treatment alternatives
- Documentation of failure, contraindication, or intolerance to at least a 4-week trial of any NSAID at the maximum recommended or tolerated anti-inflammatory dose>=4 weeks
- Documentation of failure, contraindication, or intolerance to at least a 3-month trial of one DMARD, such as methotrexate, hydroxychloroquine, leflunomide, or sulfasalazine>=3 months
Tuberculosis screening: Active or latent TB has been ruled out

Rheumatoid arthritis initial therapy criteria

Covered for moderately to severely active RA in combination with methotrexate or an alternative DMARD when methotrexate is contraindicated or not tolerated.

Rheumatoid arthritis

Individual is at least 18 years old>=18 years
ONE of the following prior-treatment pathways
- Persistent disease despite at least 3 months of methotrexate>=3 months
- Methotrexate is contraindicated or not tolerated and the individual has completed a 3-month trial of a different DMARD, such as sulfasalazine, hydroxychloroquine, or leflunomide3 months
Active or latent TB has been ruled out

Revised initial rheumatoid arthritis therapy criteria

Golimumab is considered medically necessary and covered for moderately to severely active rheumatoid arthritis when all criteria are met.

Initial rheumatoid arthritis coverage

The individual is at least 18 years old and has moderately to severely active rheumatoid arthritisAge >= 18
ONE of the following prior DMARD pathways
- Persistent disease despite at least three months of methotrexateMTX >= 3 months
- Methotrexate is contraindicated or not tolerated and the individual has completed a three-month trial of another DMARDAlternative DMARD trial = 3 months
  Examples include sulfasalazine, hydroxychloroquine, and leflunomide