CurrentCignaPolicy N/A

prior_authorization_request_form_simponi_aria

A Cigna prior authorization request form to collect clinical and administrative information needed to request coverage for Simponi Aria (golimumab IV). It captures patient, prescriber, administration, diagnosis, prior therapy, and clinical response details to support authorization decisions.

Policy Summary

PayerCigna

Policyprior_authorization_request_form_simponi_aria

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionFax completed form to (855) 840-1678 or submit online via covermymeds.com or SureScripts; urgent requests should call (800) 882-4462 to expedite.

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

1Form for single drug (Simponi Aria)

5Primary indicated diagnoses captured

3Common prior-therapy thresholds enforced (3-6 months)

Policy snapshot & purpose

A Cigna prior authorization request form to collect clinical and administrative information needed to request coverage for Simponi Aria (golimumab IV). This is a prior authorization request form for intravenous golimumab (Simponi Aria).

Authorization information / clinical criteria collection

Authorization Information / Clinical Criteria Collection

Form collects required clinical criteria and attestations; responses may be used by reviewer to determine medical necessity

Authorization Information / Clinical Criteria Collection - Top level

General required fields
- Medication requested: Simponi Aria 50mg (golimumab intravenous). Include dose, quantity, duration, J-Code, frequency, ICD-10
- Diagnosis selection: Diagnosis related to use: select one or more: ankylosing spondylitis (AS); polyarticular juvenile idiopathic arthritis (PJIA); psoriatic arthritis (PsA); rheumatoid arthritis (RA); ulcerative colitis (UC); other (specify)
- Procurement and administration setting: Provide setting of medication procurement and administration: Accredo Specialty Pharmacy; hospital outpatient; retail pharmacy; home health/home infusion; physician office stock; other. Provide facility name/address/tax ID as applicable.
- Concomitant biologic/TSM: For all indications: Will the requested medication be used in combination with a biologic or a targeted synthetic oral small molecule? (Yes/No)
- Current Simponi use: Is the patient currently receiving Simponi (Aria or SC)? (Yes/No)
Indication-specific blocks (each includes a set of required attestations)
- If Rheumatoid arthritis
  - Prior Simponi duration: Has the patient already received at least 6 months of therapy with Simponi (Aria or SC)? (Answer No if <6 months or restarting).>= 6 months
  - Objective response: Has the patient experienced a beneficial clinical response when assessed by at least one objective measure? (Yes/No). Examples: CDAI, DAS28-ESR/CRP, PAS-II, RAPID-3, SDAI.
  - Symptom improvement: Has the patient experienced improvement in at least one symptom (decreased joint pain, morning stiffness, fatigue; improved function; decreased soft tissue swelling)? (Yes/No)
  - Rheumatology prescriber:

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Requested codes and diagnosis fields on form

Drug / HCPCS J-code (form asks for J-Code)HCPCS

No codes listed

Diagnosis codes (ICD-10) (form requests ICD10)ICD-10

No codes listed

The form explicitly requests J-Code, frequency, dose, quantity, and ICD-10 diagnosis codes as part of the medication request information.

Map to billing workflows: J-code, dose, quantity and frequency are used to populate the medical claim (or facility/infusion billing) and to calculate units and reimbursement; the ICD-10 supports medical necessity linkage on the claim. If the administration setting is hospital outpatient or physician office stock, the form may request facility details including Facility/Tax ID to route billing to the correct provider/facility payer ID.

Short guidance: Ensure J-code and ICD-10 match the ordered product and indication, record dose/frequency and quantity precisely for claim units, and provide facility name and Tax ID when the drug will be billed through a hospital outpatient or facility pathway.

Submission, documentation & billing requirements

Prior Authorization

Submit completed prior authorization form

Fax completed form to (855) 840-1678 or submit online via covermymeds.com or SureScripts. For URGENT requests call (800) 882-4462 to expedite.

Documentation Required

Provide clinical response and prior therapy documentation

Provide objective disease activity measures, documentation of symptom improvement, and prior therapy history. Include prior conventional DMARD and prior biologic trials with dates and durations, and rationale if the patient is not a candidate for alternate settings or home infusion.

Billing Rule

Specify administration setting and billing pathway

Indicate where the drug will be obtained and where it will be administered (Accredo Specialty Pharmacy; Hospital Outpatient; Retail pharmacy; Home Health/Home Infusion vendor; Physician's office stock; Other). If applicable, provide facility name, address, and Tax ID for dispensing/administration and note billing on a medical claim form when physician office stock will be used.

Documentation Required

Prescriber attestation and signature

Prescriber must sign and date the attestation certifying the information is true and accurate. The health plan or its designee may perform routine audits and request medical records to verify the information.

Definitions & form context

This administrative prior authorization form is used by Cigna to gather the clinical and administrative information required to evaluate coverage for intravenous golimumab (Simponi Aria).

The form requests indication-specific response items and attestations (for RA, AS, PsA, JIA, UC and other diagnoses) to support medical necessity determinations and documents site-of-care and pharmacy sourcing (for example, Accredo Specialty Pharmacy, hospital outpatient, home infusion, physician office stock).

Definitions

Simponi Aria: Golimumab intravenous formulation.

Conventional synthetic DMARDs: Examples include methotrexate (oral or injectable), leflunomide, hydroxychloroquine, and sulfasalazine.