Simponi (golimumab subcutaneous injection) — Cigna

Initial criteria

• Patient is age ≥ 18 years
• Patient meets ONE of the following: (a) Patient has arthritis primarily in the knees, ankles, elbows, wrists, hands, and/or feet AND has tried at least one conventional synthetic DMARD (e.g., methotrexate, leflunomide, sulfasalazine); OR (b) Patient has axial spondyloarthritis AND has objective signs of inflammation defined as at least ONE of the following: (1) C-reactive protein elevated beyond the upper limit of normal; OR (2) Sacroiliitis reported on magnetic resonance imaging
• The medication is prescribed by or in consultation with a rheumatologist

Reauthorization criteria

• Patient has been established on therapy for at least 6 months
• Patient meets at least ONE of the following: (a) When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (e.g., Ankylosing Spondylitis Disease Activity Score, serum markers such as C-reactive protein or erythrocyte sedimentation rate); OR (b) Compared with baseline (prior to initiating Simponi), patient experienced an improvement in at least one symptom such as decreased pain or stiffness, or improvement in function or activities of daily living

Approval duration

initial 6 months; reauth 1 year