CurrentMass General Brigham Health PlanPolicy N/A

Simponi Aria (golimumab) prior authorization — pharmacy benefit

Prior authorization policy governing outpatient pharmacy coverage and specialty pharmacy dispensing of intravenous Simponi Aria (golimumab) for Commercial/Exchange members of Mass General Brigham Health Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicySimponi Aria (golimumab) prior authorization — pharmacy benefit

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateMay 1, 2026

Key ActionSubmit prior authorization and supporting medical records demonstrating required diagnosis-specific criteria or current treatment for new-to-plan members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 moinitial and reauthorization approval duration

4 vials/8wpharmacy quantity limit

Commercial/Exchangeplan applicability

Specialty Rxdispensing

Coverage Criteria for Simponi Aria (golimumab)

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Initial Therapy Criteria

Authorization may be granted when ALL diagnosis-specific criteria below are met for the relevant indication OR when member is new to plan and currently receiving therapy (with records):

Pathways to approval: Either A OR B must be met: A) New-to-plan member with documentation of current treatment with the requested drug (coverage effective date \u2264 90 days). B) Member meets ALL criteria for the specific diagnosis as listed below.

See documentation requirements for new-to-plan members.

Rheumatoid arthritis (RA): 1) Diagnosis of moderately to severely active rheumatoid arthritis (RA). 2) Member has minimum duration of a 3-month trial and failure, intolerance, or contraindication to ONE of the following conventional therapies at maximally tolerated doses: methotrexate, leflunomide, or sulfasalazine.3-month trial

Psoriatic arthritis (PsA): 1) Diagnosis of active psoriatic arthritis (PsA). 2) Member has ONE of: actively inflamed joints, dactylitis, enthesitis, axial disease, or active skin and/or nail involvement.

No specific prior conventional therapy required per policy.

Ankylosing spondylitis (AS): 1) Diagnosis of active ankylosing spondylitis. 2) Member has minimum duration of a 1-month trial and failure, intolerance, or contraindication to TWO different NSAIDs at maximally tolerated doses (examples: ibuprofen, naproxen).1-month trial of two NSAIDs

Polyarticular juvenile idiopathic arthritis (pJIA): 1) Diagnosis of active polyarticular juvenile idiopathic arthritis (pJIA). 2) Member has a minimum duration of a 6-week trial and failure, intolerance, or contraindication to ONE of the following conventional therapies at maximally tolerated doses: leflunomide or methotrexate.6-week trial

Continuation of Therapy

Reauthorization will be granted when ALL of the following are met:

Clinical response: Submission of medical records (e.g., chart notes) demonstrating an improvement in the member's condition, evidenced by low disease activity or improvement in signs and symptoms of the condition.

Approvals granted for up to 24 months per policy.

Dosing and quantity limits: Requested dosing and quantity must be consistent with policy limits (pharmacy quantity limit: 4 vials per 8 weeks) and prescribing information.4 vials/8 weeks

Specialty pharmacy dispensing required per plan.

This prior authorization policy applies only to the pharmacy benefit for Commercial/Exchange members and governs outpatient pharmacy and specialty pharmacy dispensing of intravenous Simponi Aria (golimumab). The policy was updated to indicate it no longer applies to the medical benefit (see policy effective dates and review history).

Simponi Aria has been designated a specialty medication and must be dispensed through a contracted specialty pharmacy per the benefit specifications. Contact information for pharmacy benefit prior authorization is available in the policy.

Provider Requirements, Documentation, and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for pharmacy benefit dispensing of Simponi Aria (golimumab) for Commercial/Exchange members. Approval is contingent on meeting the coverage criteria described below and specialty pharmacy dispensing requirements.

Plan: Commercial/Exchange
Program Type: Prior Authorization
Benefit: Pharmacy Benefit
Specialty: Must be filled at a contracted specialty pharmacy

Documentation Required

Required Documentation

For new-to-plan members (coverage effective date ≤ 90 days), submit medical records documenting the member is currently receiving treatment with the requested drug (excludes samples or manufacturer's patient assistance program-supplied product). For continuation/reauthorization requests, submit chart notes or other medical records demonstrating improvement in the member's condition, such as low disease activity or improvement in signs and symptoms.

New-to-plan (≤ 90 days): medical records documenting current treatment with the requested drug
Continuation: medical records demonstrating clinical improvement (low disease activity or improved signs/symptoms)

Step Therapy

Prior Therapy Requirements

Prior therapy requirements must be met before authorization depending on the diagnosis. See the specific diagnostic criteria below — documentation of trials, durations, and failure/intolerance/contraindication is required.

Rheumatoid arthritis (RA): 3-month trial and failure, intolerance, or contraindication to ONE conventional therapy at maximally tolerated dose (methotrexate, leflunomide, or sulfasalazine).
Psoriatic arthritis (PsA): Documentation of active disease evidenced by one or more of: actively inflamed joints, dactylitis, enthesitis, axial disease, or active skin/nail involvement.
Ankylosing spondylitis (AS): 1-month trial and failure, intolerance, or contraindication to TWO different NSAIDs at maximally tolerated doses.
Polyarticular juvenile idiopathic arthritis (pJIA): 6-week trial and failure, intolerance, or contraindication to ONE conventional therapy at maximally tolerated dose (leflunomide or methotrexate).

Denial Risk

Denial Triggers / Documentation Risk

Requests may be denied if required documentation is not provided or if the diagnosis or prior therapy requirements are not met. New-to-plan members without medical records documenting current receipt of the requested drug may have requests denied.

Denial trigger: New-to-plan (≤ 90 days) without documentation of current treatment with the requested drug
Denial trigger: Insufficient documentation of required prior therapy trials, durations, or failures/intolerances/contraindications
Denial trigger: Diagnosis does not meet covered criteria

Background and Clinical Context

Golimumab (Simponi Aria) is an intravenous tumor necrosis factor (TNF) inhibitor indicated for inflammatory arthritides including moderately to severely active rheumatoid arthritis (in combination with methotrexate), active psoriatic arthritis, active ankylosing spondylitis, and polyarticular juvenile idiopathic arthritis in patients aged ≥2 years where specified. The policy covers the intravenous formulation supplied via specialty pharmacy under the pharmacy benefit.

Reviewers should note that clinical authorization decisions are based on diagnosis-specific criteria (for RA, PsA, AS, and pJIA) including required prior therapy trials for some indications and documentation of clinical response for reauthorization. The policy history documents updates to indications, prior-therapy language, quantity limits, and the recent clarification that coverage is limited to the pharmacy benefit.

OpenPayer

Simponi Aria (golimumab) prior authorization — pharmacy benefit

Coverage Criteria for Simponi Aria (golimumab)

Provider Requirements, Documentation, and Prior Authorization

Drug Definition and Key Terms

Background and Clinical Context