CurrentunitedhealthcarePolicy 2026D0051S

Simponi Aria (Golimumab) Injection for Intravenous Infusion Policy

Medical benefit drug policy governing coverage criteria, initial and continuation authorization requirements, and applicable billing/diagnosis codes for Simponi Aria (golimumab) injection for intravenous infusion for UnitedHealthcare commercial members. This part (1 of 2) includes coverage rationale for multiple indications and a long list of applicable diagnosis codes and the HCPCS J-code.

Policy Summary

Payerunitedhealthcare

PolicySimponi Aria (Golimumab) Injection for Intravenous Infusion Policy

Policy CodePolicy 2026D0051S

Change TypeRevisions to prior-therapy examples and combination exclusions

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain prior authorization and document diagnosis, prior therapy trials or prior biologic use, FDA‑concordant dosing, and positive clinical response for reauthorization.

SourceLink

POLICY UPDATE CHANGES

Updated list of examples of systemic targeted immunomodulators U.S. FDA approved for ankylosing spondylitis with which the patient has been previously treated for initial therapy; added adalimumab, bimekizumab, secukinumab, baricitinib, abatacept, ixekizumab.

Added Bimzelx (bimekizumab-bkzx), Cosentyx (secukinumab), and Taltz (ixekizumab) to the list of systemic targeted immunomodulators the patient must not be receiving in combination with Simponi Aria for ankylosing spondylitis.

Updated Psoriatic Arthritis prior-therapy examples: added bimekizumab and replaced 'Stelara (ustekinumab)' with 'ustekinumab'; replaced 'Xeljanz (tofacitinib)' with 'Xeljanz/ Xeljanz XR (tofacitinib)'.

Updated Psoriatic Arthritis combination exclusions: added bimekizumab, removed baricitinib, and updated nomenclature for ustekinumab and tofacitinib.

Rheumatoid Arthritis: removed 'Simponi (golimumab)' from prior-therapy examples and updated Xeljanz nomenclature to 'Xeljanz/ Xeljanz XR (tofacitinib)'.

Polyarticular Juvenile Idiopathic Arthritis: removed 'Simponi (golimumab)' from combination exclusions and updated Xeljanz nomenclature.

Replaced 'targeted immunomodulator' with 'systemic targeted immunomodulator' in coverage rationale.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Summary

This policy governs medical-benefit coverage for Simponi Aria (golimumab) injection for intravenous infusion and is effective 03/01/2026 (Policy: Simponi Aria (Golimumab) Injection for Intravenous Infusion). The policy applies to UnitedHealthcare commercial medical benefit members and lists coverage criteria, authorization durations, and applicable billing/diagnosis codes (including HCPCS J1602 and extensive ICD‑10 diagnosis code listings).

Covered indications in this policy include: ankylosing spondylitis (AS), psoriatic arthritis (PsA), rheumatoid arthritis (RA), and polyarticular juvenile idiopathic arthritis (pJIA), with proven and medically necessary criteria and initial/continuation authorization requirements specified for each indication.

Note: the policy refers only to the intravenous formulation (Simponi Aria) under the medical benefit. The self‑administered subcutaneous Simponi product is obtained under the pharmacy benefit unless the member's benefit plan specifies otherwise.

Initial Therapy Criteria (by indication)

Continuation Therapy Criteria (by indication)

Prior Therapy Examples and Combination Exclusions (updates)

Policy revisions include updates to terminology and to examples of systemic targeted immunomodulators used in prior‑therapy and combination‑exclusion lists across indications; these changes are reflected in the prior‑therapy and combination exclusion examples in the policy.

This policy version has a material change in prior‑therapy examples and combination exclusions (has_material_change = true).

Applicable Codes

HCPCS (drug)HCPCSCovered

J1602

Injection, golimumab, 1 mg

Applicable Diagnosis Codes (ICD-10) - referenced for indicationsICD-10

M45.0	Ankylosing spondylitis of multiple sites in spine
M07.0	Psoriatic juvenile arthropathy
M07.3	Arthritis in other diseases classified elsewhere

Applicable ICD-10 Diagnosis Codes (rheumatologic diagnoses listed)ICD-10

M05.39	Rheumatoid arthritis with rheumatoid factor of unspecified site, other involvement
M05.40	Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M05.411	Rheumatoid arthritis with rheumatoid factor of right shoulder
M05.412	Rheumatoid arthritis with rheumatoid factor of left shoulder
M05.419	Rheumatoid arthritis with rheumatoid factor of unspecified shoulder
M05.421	Rheumatoid arthritis with rheumatoid factor of right elbow
M05.422	Rheumatoid arthritis with rheumatoid factor of left elbow
M05.429	Rheumatoid arthritis with rheumatoid factor of unspecified elbow
M05.431	Rheumatoid arthritis with rheumatoid factor of right wrist
M05.432	Rheumatoid arthritis with rheumatoid factor of left wrist

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Provider Actions and Documentation Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for initial and continuation therapy of Simponi Aria (golimumab) IV infusion. Authorization is limited to no more than 12 months and requests must include documentation of diagnosis, prior therapy trials or prior biologic use (per indication), FDA-concordant dosing, and positive clinical response for reauthorization.

J1602

Prior Authorization

Prior authorization and combination-exclusion requirements

Prior authorization requires documentation of prior treatments (or reasons for not using them) per the indication and Simponi Aria must not be given in combination with specified systemic targeted immunomodulators for the same indication. Providers must document prior medication history or prior biologic use and ensure the patient is not receiving the excluded agents listed for the applicable indication.

Clinical Evidence Summary

208AS trial: golimumab 2 mg/kg IV, ASAS20 improvement at Week 16; dosing Weeks 0,4,12 then every 8 weeks through Week 52

480PsA trial: golimumab 2 mg/kg IV, ACR20 improvement at Week 14; dosing Weeks 0,4,12,20 then continued (placebo crossover by Week 24)

100+RA GO-FURTHER extension: sustained ACR responses and radiographic results through 100 weeks; safety monitored to 112 weeks

127pJIA study: open‑label single‑arm supportive study in children 2 to <18 y; dosing 80 mg/m2 IV at Weeks 0,4 and every 8 weeks through Week 52

Supporting evidence cited in the policy includes pivotal trials and extension/open‑label studies with commonly used trial endpoints: the AS study used the ASAS20 endpoint (assessed at Week 16), the PsA trial used the ACR20 endpoint (assessed at Week 14), the RA program includes the GO‑FURTHER long‑term extension with sustained ACR responses through Week 100, and the pediatric pJIA study is an open‑label single‑arm supportive study in children 2 to <18 years.

Dosing schedules reported in trials include IV golimumab given at listed weeks (AS: Weeks 0, 4, 12 with continued dosing through Week 52; PsA: Weeks 0, 4, 12, 20 then continued every 8 weeks; RA: Weeks 0, 4, and every 8 weeks; pJIA: 80 mg/m2 IV at Weeks 0, 4, and every 8 weeks through Week 52). These studies are cited as supportive evidence in the policy.

Background and Definitions

Background: This policy covers administration of Simponi Aria (golimumab) IV infusion under the medical benefit. The self‑administered subcutaneous Simponi product is managed under the pharmacy benefit except where a member's plan specifies otherwise.

Indications covered include ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. This part of the policy (Part 2 of 2) includes coverage rationale, continuation/reauthorization expectations, and the applicable diagnosis (ICD‑10) and HCPCS code listings used for billing and prior authorization.

Definitions:

Systemic targeted immunomodulator: Policy term referring to systemic biologic or targeted small‑molecule agents used to treat rheumatologic conditions (policy examples and updated nomenclature are provided in the coverage rationale and prior‑therapy lists).

Revision History

03/01/2026revisedLatest

Policy effective 2026-03-01. Terminology change: replaced 'targeted immunomodulator' with 'systemic targeted immunomodulator' in coverage rationale; multiple indication-specific prior-therapy example lists and combination-exclusion lists were updated (see detailed items).

03/01/2026revisedLatest

Ankylosing spondylitis prior-therapy examples expanded to add adalimumab, Bimzelx (bimekizumab-bkzx), Cosentyx (secukinumab), Olumiant (baricitinib), Orencia (abatacept), and Taltz (ixekizumab).

Policy Summary

Payerunitedhealthcare

PolicySimponi Aria (Golimumab) Injection for Intravenous Infusion Policy

Policy CodePolicy 2026D0051S

Change TypeRevisions to prior-therapy examples and combination exclusions

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain prior authorization and document diagnosis, prior therapy trials or prior biologic use, FDA‑concordant dosing, and positive clinical response for reauthorization.

SourceLink

On This Page

Documentation Required

Document prior therapy or intolerance

Document failure or intolerance to required prior therapies per indication. Examples: ankylosing spondylitis — failure to two NSAIDs at maximally indicated doses, each used for at least 4 weeks; psoriatic arthritis — a 3-month trial of methotrexate at maximally indicated dose; rheumatoid arthritis — a 3-month trial of one non-biologic DMARD at maximally indicated doses (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine), unless contraindicated or intolerant.

AS: two NSAIDs, each used ≥ 4 weeks at maximally indicated dose
PsA: 3-month methotrexate trial at maximally indicated dose
RA: 3-month trial of one non-biologic DMARD at maximally indicated doses

Documentation Required

Clinical evidence/documentation expectations

For prior authorization and reauthorization, document the diagnosis, relevant disease activity measures, prior medication history (including NSAIDs, DMARDs, biologics or other systemic targeted immunomodulators) or reasons for intolerance, and evidence of clinical response for continuation. Reauthorizations are limited to no more than 12 months and must show positive clinical response and FDA-concordant dosing.

Document diagnosis and disease activity measures consistent with trials/FDA labeling
Document prior medication history and reasons for intolerance or failure
Provide evidence of positive clinical response for reauthorization; reauthorization ≤ 12 months