Simponi Aria — Medica
Other Conditions
Preferred products
- Humira
- Amjevita
- Stelara subcutaneous
Initial criteria
- Patient meets the standard Inflammatory Conditions – Simponi Subcutaneous Prior Authorization Policy criteria
- AND has tried step therapy as follows by indication:
- • Rheumatoid Arthritis: tried TWO of Actemra subcutaneous, Enbrel, an adalimumab product (Humira, Amjevita), Rinvoq, and Xeljanz/XR [documentation required];
- • Ankylosing Spondylitis: tried TWO of Enbrel, an adalimumab product (Humira, Amjevita), Rinvoq, Taltz, Xeljanz/XR [documentation required];
- • Psoriatic Arthritis: tried TWO of Enbrel, an adalimumab product (Humira, Amjevita), Otezla, Rinvoq, Skyrizi subcutaneous, Stelara subcutaneous, Taltz, Tremfya, and Xeljanz/XR [documentation required];
- • Ulcerative Colitis: tried one adalimumab product (Humira, Amjevita).
Reauthorization criteria
- Patient meets BOTH of the following (i and ii):
- i. Patient meets the standard Inflammatory Conditions – Simponi Subcutaneous Prior Authorization Policy criteria; AND
- ii. Patient meets ONE of the following conditions (a–f):
- a) Rheumatoid Arthritis: tried TWO of Actemra subcutaneous, Enbrel, an adalimumab product (Humira, Amjevita), Rinvoq, and Xeljanz/XR [documentation required]; OR
- b) Ankylosing Spondylitis: tried TWO of Enbrel, an adalimumab product (Humira, Amjevita), Rinvoq, Taltz, Xeljanz/XR [documentation required]; OR
- c) Psoriatic Arthritis: tried TWO of Enbrel, an adalimumab product (Humira, Amjevita), Otezla, Rinvoq, Skyrizi subcutaneous, Stelara subcutaneous, Taltz, Tremfya, and Xeljanz/XR [documentation required]; OR
- d) Ulcerative Colitis: tried one adalimumab product (Humira, Amjevita); OR
- e) Patient established on Simponi Aria ≥90 days; OR
- f) Patient established on Simponi subcutaneous ≥90 days with paid prescription claims verifying a ≥90-day supply within past 130 days or prescriber verification.
Approval duration
initial 6 months; reauthorization 1 year