Sierra Health and Life Simponi Aria IV Coverage Update

Coverage Criteria for Simponi Aria (golimumab) IV

Ankylosing Spondylitis - Initial and Continuation Therapy

Covered when ALL of the following are met

AS Initial Therapy

Prior treatment: One of the following: history of failure to two NSAIDs each used at maximally indicated doses for ≥4 weeks unless contraindicated OR previously treated with a systemic targeted immunomodulator FDA-approved for AS OR patient is currently on Simponi Aria.

AS Continuation Therapy: Patient has previously received Simponi Aria IV; documentation of positive clinical response to Simponi Aria; dosing for ankylosing spondylitis is in accordance with FDA labeled dosing; patient is not receiving Simponi Aria in combination with a systemic targeted immunomodulator for the same indication (examples as above); reauthorization is for no more than 12 months.

Psoriatic Arthritis - Initial and Continuation Therapy

Covered when ALL of the following are met

PsA Initial Therapy

Prior treatment: One of the following: history of failure to a 3-month trial of methotrexate at maximally indicated dose unless contraindicated OR previously treated with a systemic targeted immunomodulator FDA-approved for PsA OR patient is currently on Simponi Aria.

PsA Continuation Therapy: Patient has previously received Simponi Aria IV; documentation of positive clinical response to Simponi Aria; dosing for psoriatic arthritis is in accordance with FDA labeled dosing; patient is not receiving Simponi Aria in combination with a systemic targeted immunomodulator for the same indication (examples as above); reauthorization is for no more than 12 months.

Rheumatoid Arthritis - Initial and Continuation Therapy

Covered when ALL of the following are met

RA Initial Therapy: Diagnosis of moderately to severely active rheumatoid arthritis (RA); one of the following: patient is receiving concurrent methotrexate OR history of contraindication or intolerance to methotrexate OR history of failure/intolerance to a 3-month trial of one non-biologic DMARD at maximally indicated dose unless contraindicated OR previously treated with a systemic targeted immunomodulator FDA-approved for RA OR patient is currently on Simponi Aria; Simponi Aria is initiated and titrated according to US FDA labeled dosing for rheumatoid arthritis; patient is not receiving Simponi Aria in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab, certolizumab, etanercept, baricitinib, abatacept, upadacitinib, tofacitinib); initial authorization is for no more than 12 months; prescribed by or in consultation with a rheumatologist.

RA Continuation Therapy: Patient has previously received Simponi Aria IV; documentation of positive clinical response to Simponi Aria; dosing for rheumatoid arthritis is in accordance with FDA labeled dosing; patient is not receiving Simponi Aria in combination with a systemic targeted immunomodulator for the same indication (examples as above); reauthorization is for no more than 12 months.

Polyarticular Juvenile Idiopathic Arthritis - Initial and Continuation Therapy

Covered when ALL of the following are met

PJIA Initial Therapy: Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis (PJIA); Simponi Aria is initiated and titrated according to US FDA labeled dosing for PJIA; patient is not receiving Simponi Aria in combination with a systemic targeted immunomodulator for treatment of the same indication (examples: adalimumab, certolizumab, etanercept, baricitinib, abatacept, upadacitinib, tofacitinib); initial authorization is for no more than 12 months; prescribed by or in consultation with a rheumatologist.

PJIA Continuation Therapy: Patient has previously received Simponi Aria IV; documentation of positive clinical response to Simponi Aria; Simponi Aria is dosed according to FDA labeled dosing for PJIA; patient is not receiving Simponi Aria in combination with a systemic targeted immunomodulator for the same indication (examples as above); reauthorization is for no more than 12 months.

Evidence summaries by indication

Clinical trial-based indications and evidence summaries (informational; not explicit policy coverage decision in this chunk).

Ankylosing Spondylitis trial evidence: In a randomized placebo-controlled trial of 208 adults with active AS (BASDAI ≥4, VAS total back pain ≥4, hsCRP ≥0.3 mg/dL), IV golimumab 2 mg/kg given at Weeks 0, 4 and 12 resulted in significant improvement vs placebo in ASAS20 at Week 16; dosing continued at Week 20 and every 8 weeks through Week 52; concomitant stable MTX, SSZ, HCQ, low‑dose corticosteroids and/or NSAIDs were permitted; other DMARDs/biologics were prohibited.BASDAI ≥4; VAS ≥4; hsCRP ≥0.3 mg/dL

See trial details.

Psoriatic Arthritis trial evidence: In a randomized placebo-controlled trial of 480 adults with active PsA (≥5 swollen and ≥5 tender joints and CRP ≥0.6 mg/dL), IV golimumab 2 mg/kg at Weeks 0, 4, 12 and 20 demonstrated significant ACR20 responses at Week 14 versus placebo; concomitant stable MTX, NSAIDs and low‑dose corticosteroids permitted; other DMARDs/biologics prohibited.≥5 swollen and ≥5 tender joints; CRP ≥0.6 mg/dL

See trial details.

Revised coverage criteria — indication-specific

Coverage criteria were revised for multiple indications with updated lists of systemic targeted immunomodulators required as prior therapy or prohibited in combination.

Ankylosing Spondylitis criteria revisions: Updated examples of systemic targeted immunomodulators U.S. FDA approved for AS that count as prior therapy (added adalimumab, bimekizumab, secukinumab, baricitinib, abatacept, ixekizumab) and updated prohibited-combination examples to add bimekizumab, secukinumab, and ixekizumab.

See policy history for itemization.

Psoriatic Arthritis criteria revisions: Added bimekizumab to prior therapy examples and standardized naming of ustekinumab; updated prohibited-combination examples to add bimekizumab and to replace or remove certain agents.

See policy history.

Rheumatoid Arthritis criteria revisions: Removed Simponi (golimumab) from prior-therapy examples and standardized Xeljanz naming to 'Xeljanz/ Xeljanz XR (tofacitinib)'; prohibited-combination examples updated accordingly.

See policy history.

Requests for Simponi Aria for any listed indication are not allowed to be written or approved in combination with another systemic targeted immunomodulator for the same clinical indication. The policy provides example agents that meet this prohibition (e.g., adalimumab, bimekizumab, certolizumab, secukinumab, etanercept, baricitinib, abatacept, upadacitinib, ixekizumab, tofacitinib) and requires that the patient is not concurrently receiving such an agent when Simponi Aria is prescribed for ankylosing spondylitis, psoriatic arthritis, or polyarticular juvenile idiopathic arthritis.

FDA approval information for Simponi Aria is provided for informational purposes only. FDA approval alone is not a basis for coverage; coverage determinations must also reference the member-specific benefit plan and any applicable federal or state mandates, which may supersede policy language.

Policy history includes updated, indication-specific lists of systemic targeted immunomodulators used both as examples of prior therapies and as prohibited concomitant agents. These lists were revised on 03/01/2026 (items added, removed, or renamed across indications); see the policy history for the itemized changes to the agents that count as prior therapy or that are excluded from concurrent use with Simponi Aria.

Procedure and Diagnosis Codes

Applicable HCPCSHCPCS

J1602

Injection, golimumab, 1 mg, for intravenous use.

Applicable ICD-10 diagnosis codes (partial list)ICD-10

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.A	Abnormal rheumatoid factor and anti-citrullinated protein antibody with rheumatoid arthritis.
M05.00	Felty's syndrome, unspecified site.

Applicable HCPCS / drug administration codeHCPCS

J1602

Injection, golimumab, 1 mg, for intravenous use.

Applicable ICD-10 Codes (partial list shown)ICD-10

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.A	Abnormal rheumatoid factor and anti-citrullinated protein antibody with rheumatoid arthritis.
M05.00	Felty's syndrome, unspecified site.
M05.011	Felty's syndrome, right shoulder.
M05.012	Felty's syndrome, left shoulder.

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Juvenile rheumatoid arthritis codes (partial list shown in chunk 36)ICD-10Covered

M08.021	Unspecified juvenile rheumatoid arthritis, right elbow.
M08.022	Unspecified juvenile rheumatoid arthritis, left elbow.
M08.029	Unspecified juvenile rheumatoid arthritis, unspecified elbow.
M08.031	Unspecified juvenile rheumatoid arthritis, right wrist.
M08.032	Unspecified juvenile rheumatoid arthritis, left wrist.
M08.039	Unspecified juvenile rheumatoid arthritis, unspecified wrist.
M08.041	Unspecified juvenile rheumatoid arthritis, right hand.
M08.042	Unspecified juvenile rheumatoid arthritis, left hand.
M08.049	Unspecified juvenile rheumatoid arthritis, unspecified hand.
M08.051	Unspecified juvenile rheumatoid arthritis, right hip.

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Juvenile rheumatoid/systemic onset codes (continued)ICD-10Covered

M08.071	Unspecified juvenile rheumatoid arthritis, right ankle and foot.
M08.072	Unspecified juvenile rheumatoid arthritis, left ankle and foot.
M08.079	Unspecified juvenile rheumatoid arthritis, unspecified ankle and foot.
M08.08	Unspecified juvenile rheumatoid arthritis, vertebrae.
M08.09	Unspecified juvenile rheumatoid arthritis, multiple sites.
M08.20	Juvenile rheumatoid arthritis with systemic onset, unspecified site.
M08.211	Juvenile rheumatoid arthritis with systemic onset, right shoulder.
M08.212	Juvenile rheumatoid arthritis with systemic onset, left shoulder.
M08.219	Juvenile rheumatoid arthritis with systemic onset, unspecified shoulder.
M08.221	Juvenile rheumatoid arthritis with systemic onset, right elbow.

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Other juvenile arthritis and unspecified juvenile arthritis codesICD-10Covered

M08.259	Juvenile rheumatoid arthritis with systemic onset, unspecified hip.
M08.261	Juvenile rheumatoid arthritis with systemic onset, right knee.
M08.262	Juvenile rheumatoid arthritis with systemic onset, left knee.
M08.269	Juvenile rheumatoid arthritis with systemic onset, unspecified knee.
M08.271	Juvenile rheumatoid arthritis with systemic onset, right ankle and foot.
M08.272	Juvenile rheumatoid arthritis with systemic onset, left ankle and foot.
M08.279	Juvenile rheumatoid arthritis with systemic onset, unspecified ankle and foot.
M08.28	Juvenile rheumatoid arthritis with systemic onset, multiple sites.
M08.3	Juvenile rheumatoid polyarthritis (seronegative).
M08.80	Other juvenile arthritis, unspecified site.

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Continued juvenile arthritis codesICD-10Covered

M08.841	Other juvenile arthritis, right hand.
M08.842	Other juvenile arthritis, left hand.
M08.849	Other juvenile arthritis, unspecified hand.
M08.851	Other juvenile arthritis, right hip.
M08.852	Other juvenile arthritis, left hip.
M08.859	Other juvenile arthritis, unspecified hip.
M08.861	Other juvenile arthritis, right knee.
M08.862	Other juvenile arthritis, left knee.
M08.869	Other juvenile arthritis, unspecified knee.
M08.871	Other juvenile arthritis, right ankle and foot.

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Juvenile arthritis unspecified site codesICD-10Covered

M08.911	Juvenile arthritis, unspecified, right shoulder.
M08.912	Juvenile arthritis, unspecified, left shoulder.
M08.919	Juvenile arthritis, unspecified, unspecified shoulder.
M08.921	Juvenile arthritis, unspecified, right elbow.
M08.922	Juvenile arthritis, unspecified, left elbow.
M08.929	Juvenile arthritis, unspecified, unspecified elbow.
M08.931	Juvenile arthritis, unspecified, right wrist.
M08.932	Juvenile arthritis, unspecified, left wrist.
M08.939	Juvenile arthritis, unspecified, unspecified wrist.
M08.941	Juvenile arthritis, unspecified, right hand.

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Remaining juvenile arthritis and ankylosing spondylitis codesICD-10Covered

M08.961	Juvenile arthritis, unspecified, right knee.
M08.962	Juvenile arthritis, unspecified, left knee.
M08.971	Juvenile arthritis, unspecified, right ankle and foot.
M08.972	Juvenile arthritis, unspecified, left ankle and foot.
M08.979	Juvenile arthritis, unspecified, unspecified ankle and foot.
M08.98	Juvenile arthritis, unspecified, vertebrae.
M08.99	Juvenile arthritis, unspecified, multiple sites.
M08.9A	Juvenile arthritis, unspecified, other specified site.
M08.1	Juvenile ankylosing spondylitis.
M45.5	Ankylosing spondylitis of thoracolumbar region.

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AS trial BASDAI and pain thresholds

Trial population size208 adult patients in pivotal AS trial

AS trial hsCRP threshold

ContextRequired at baseline for inclusion in AS pivotal IV golimumab trial

Dosing in trialGolimumab 2 mg/kg IV at Weeks 0, 4, 12 (then continued per protocol)

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Simponi Aria (golimumab IV). Initial approvals are granted for up to 12 months when coverage criteria are met; reauthorization approvals are also for no more than 12 months.

Prior authorization required; initial and reauthorization approvals up to 12 months when criteria met
Prescriptions must follow FDA-labeled dosing for the specific indication

Billing Rule

Applicable Procedure / Billing Code

Use HCPCS/CPT/Drug billing code J1602 for golimumab intravenous infusions. Include an ICD-10 diagnosis code that supports the authorized indication on claims.

Background and Drug Overview

Simponi Aria (intravenous golimumab) is a human tumor necrosis factor (TNF) monoclonal antibody indicated for multiple inflammatory rheumatologic conditions. This medical-benefit policy defines FDA-consistent IV dosing and specifies indication-specific criteria for ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis, including prior-treatment and continuation requirements and limits on concurrent use with other systemic targeted immunomodulators. Prior authorization is required and approvals are granted for up to 12 months when all criteria for the applicable indication are met.

Definitions and Key Terms

Medical vs Pharmacy benefit

Benefit assignmentSimponi Aria (IV golimumab) is covered under the medical benefit (intravenous infusion)

SC SimponiSelf-administered subcutaneous Simponi is obtained under the pharmacy benefit unless member plan specifies otherwise

California exceptionFor members in UnitedHealthcare of California with delegated PA review, self-administered Simponi may be obtained under the medical benefit

Golimumab

MechanismHuman monoclonal antibody targeting both soluble and transmembrane forms of tumor necrosis factor-alpha (TNF-alpha)

Therapeutic classAnti-TNF biologic

Policy Revision History

2026-03-01material_revisionLatest

Replaced 'targeted immunomodulator' with 'systemic targeted immunomodulator' and revised indication-specific coverage criteria including updated lists of prior therapies and prohibited concomitant systemic targeted immunomodulators for ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis.

OpenPayer

Simponi Aria (Golimumab) IV infusion — Medical Benefit Drug Policy (coverage criteria)

Coverage Criteria for Simponi Aria (golimumab) IV

Procedure and Diagnosis Codes

Provider Actions, Prior Authorization and Documentation

Background and Drug Overview

Definitions and Key Terms

Policy Revision History