Simponi Subcutaneous — Cigna

Ulcerative Colitis

Preferred products

Patient meets the standard Inflammatory Conditions – Simponi Subcutaneous Prior Authorization Policy criteria
Patient meets ONE of the following (a, b, c, d, e, or f):
a) Patient has Rheumatoid Arthritis and has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR [documentation required]
b) Patient has Ankylosing Spondylitis and has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, or Xeljanz/XR [documentation required]
c) Patient has Psoriatic Arthritis and has tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya subcutaneous, or Xeljanz/XR [documentation required]
d) Patient has Ulcerative Colitis and has tried ONE of an adalimumab product, Omvoh subcutaneous, Skyrizi subcutaneous (on-body injector), an ustekinumab subcutaneous product, Tremfya subcutaneous, Velsipity, or Zymfentra
e) According to the prescriber, the patient has been established on Simponi Aria for at least 90 days
f) Patient has been established on Simponi subcutaneous for at least 90 days and prescription claims history indicates at least a 90-day supply dispensed within the past 130 days OR, if claims history unavailable, according to the prescriber

1 year