CurrentUnitedHealthcarePolicy CSOH2026D0051.D

Simponi Aria (Golimumab) Injection for Intravenous Infusion (Ohio Only)

Governs coverage and medical necessity evaluation for intravenous golimumab (Simponi Aria) under the UnitedHealthcare medical benefit in the state of Ohio; self-administered subcutaneous Simponi is managed under the pharmacy benefit.

Policy Summary

PayerUnitedHealthcare

PolicySimponi Aria (Golimumab) Injection for Intravenous Infusion (Ohio Only)

Policy CodePolicy CSOH2026D0051.D

Change TypeRoutine review — no content changes

Effective DateMar 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests demonstrating InterQual medical necessity criteria are met for Simponi Aria IV.

SourceLink

POLICY UPDATE CHANGES

03/01/2026 routine review; no content changes and previous policy version CSOH2025D0051.C archived.

J1602HCPCS code listed for golimumab IV (1 mg)

Ohio-onlyPolicy application state

InterQualClinical criteria source referenced for medical necessity

Coverage and Medical Necessity Criteria

InterQual-based Medical Necessity

Covered when criteria in the InterQual guideline for Simponi Aria (Golimumab) are met.

Policy Summary

PayerUnitedHealthcare

PolicySimponi Aria (Golimumab) Injection for Intravenous Infusion (Ohio Only)

Policy CodePolicy CSOH2026D0051.D

Change TypeRoutine review — no content changes

Effective DateMar 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests demonstrating InterQual medical necessity criteria are met for Simponi Aria IV.

SourceLink

On This Page

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InterQual-based coverage: Medical necessity and coverage for Simponi Aria IV require meeting the InterQual guideline for Simponi Aria: CP: Specialty Rx Non-Oncology, Golimumab (Simponi Aria)refer to current InterQual release

Specific clinical entry, continuation, and exclusion criteria are in the InterQual guideline; this policy references that external criteria.

This medical benefit policy covers Simponi Aria (golimumab) intravenous infusion and governs coverage and medical necessity determination for the IV formulation. The policy does not govern the self-administered subcutaneous formulation of Simponi; subcutaneous Simponi is managed under the pharmacy benefit and is not covered under this medical benefit policy. For clinical coverage criteria, including indications and entry/continuation requirements, refer to the current InterQual® guideline for Simponi Aria (Golimumab).

The listed procedure and diagnosis codes are provided for reference only. Listing of a code does not imply that the service is covered; benefit coverage and payment depend on applicable federal, state, or contractual requirements and laws. The presence of a code in this policy is not a guarantee of reimbursement and other policies or guidelines may apply.

Applicable Codes and Coding Notes

Applicable HCPCS CodesHCPCS

J1602

Injection, golimumab, 1 mg, for intravenous use

None stated

ThresholdsNone stated

NotesNo numeric or clinical thresholds are listed in the policy document.

ImplicationProviders should rely on InterQual criteria for clinical thresholds and Ohio Administrative Code for regulatory limits.

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Authorization Required

Prior authorization and medical necessity determinations for Simponi Aria (golimumab) IV are made using the current InterQual® guideline: Simponi Aria: CP: Specialty Rx Non-Oncology, Golimumab (Simponi Aria). Providers must refer to the InterQual criteria for clinical coverage details, including any sequencing, step requirements, and specific medical necessity conditions.

Refer to the current InterQual® criteria for clinical coverage and any sequencing or step requirements.
Prior authorization is required when indicated by the InterQual® guideline and UnitedHealthcare prior authorization processes.
Decisions are subject to medical necessity review in accordance with InterQual® and UnitedHealthcare policies.

Billing Rule

Code Inclusion Is Informational Only

Inclusion of a procedure or diagnosis code in this policy is for reference only. The presence of a code does not imply that the service described is covered or will be reimbursed. Benefit coverage is determined by federal, state (including the Ohio Administrative Code where applicable), or contractual requirements and applicable laws. The inclusion of a code does not guarantee claim payment.

HCPCS J1602 listed for reference only — listing does not imply coverage or payment.

Documentation Required

Policy Is Interpretive; Follow Governing Requirements

This policy is interpretive and provided to assist in applying UnitedHealthcare standard benefit plans. When deciding coverage, always reference federal, state (Ohio Administrative Code), or contractual requirements for the applicable benefit plan; those requirements govern in case of conflict. UnitedHealthcare may use third-party tools (for example, InterQual®) to assist in administering benefits.

Policy is informational and does not constitute medical advice.
Reference federal, state (Ohio Administrative Code), or contractual requirements when determining coverage.

Background

Background: This policy specifically addresses Simponi Aria, the intravenous formulation of golimumab administered by infusion. It distinguishes the IV product from the self-administered subcutaneous Simponi, which is handled through the pharmacy benefit. Medical necessity and coverage for Simponi Aria are determined using the InterQual® guideline referenced in this policy.

Definitions and Scope

Simponi Aria (golimumab) IV

Drug formulationSimponi Aria is golimumab injection for intravenous infusion (IV).

Distinction from other formulationSelf‑administered subcutaneous Simponi is obtained under the pharmacy benefit and is not covered by this medical benefit policy.

Clinical criteria sourceMedical necessity for Simponi Aria IV is determined by the InterQual guideline: Simponi Aria: CP: Specialty Rx Non‑Oncology, Golimumab (Simponi Aria).

Application (Ohio)

Geographic scopeThis Medical Benefit Drug Policy applies only to the state of Ohio.

Regulatory referenceRequests for unproven services or those with coverage/quantity limits are evaluated using Ohio Administrative Code 5160-1-01.

Interaction with benefitsBenefit coverage is determined by federal, state, or contractual requirements and applicable laws; inclusion in this policy does not guarantee coverage or payment.

Initial Therapy

Initial authorization requires meeting InterQual initial therapy criteria.

Initial therapy per InterQual: Initial coverage is based on InterQual initial criteria for Simponi Aria; follow the current InterQual guideline release.see InterQual

Policy does not reproduce InterQual decision trees; providers must consult InterQual for specifics.

Continuation Therapy

Continuation coverage follows InterQual continuation criteria.

Continuation therapy per InterQual: Continuation or maintenance use of Simponi Aria requires meeting the InterQual continuation criteria for golimumab.see InterQual

Policy defers to InterQual for detailed parameters.

Step Therapy Requirements

Step	Requirement
1	Any step therapy requirements are defined in the InterQual criteria referenced by this policy; consult the current InterQual guideline for Simponi Aria (Golimumab) for specific sequencing or step requirements.

Site of Care and Infusion Setting

Billing Rule

Infusion center — medical benefit IV administration

Simponi Aria is covered under the medical benefit as an intravenous infusion; provide and bill it as a medically administered IV infusion in the appropriate infusion center setting and follow benefit/site-specific billing rules.

Administer and document as an IV infusion under the medical benefit (not the pharmacy benefit).
Follow standard benefit and site-of-care guidance and billing rules for infusion centers.