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The Policy VaultThe Policy Vault

Simponi Aria — Medica

Ulcerative Colitis

Preferred products

  • Rheumatoid Arthritis: Actemra subcutaneous, Tyenne subcutaneous, Enbrel, adalimumab-adbm, adalimumab-adaz, adalimumab-ryvk, Simlandi, Rinvoq, Xeljanz, Xeljanz XR
  • Ankylosing Spondylitis: Enbrel, adalimumab-adbm, adalimumab-adaz, adalimumab-ryvk, Simlandi, Rinvoq, Taltz, Xeljanz, Xeljanz XR
  • Psoriatic Arthritis: Enbrel, adalimumab-adbm, adalimumab-adaz, adalimumab-ryvk, Simlandi, Otezla, Rinvoq, Rinvoq LQ, Skyrizi subcutaneous (pen or syringe), Imuldosa subcutaneous, Selarsdi subcutaneous, ustekinumab-ttwe subcutaneous, Yesintek subcutaneous, Taltz, Tremfya subcutaneous, Xeljanz, Xeljanz XR
  • Ulcerative Colitis: adalimumab-adbm, adalimumab-adaz, adalimumab-ryvk, Simlandi, Omvoh subcutaneous, Skyrizi subcutaneous (on-body injector), Imuldosa subcutaneous, Selarsdi subcutaneous, ustekinumab-ttwe subcutaneous, Yesintek subcutaneous, Tremfya subcutaneous, Velsipity, Zymfentra

Initial criteria

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

Reauthorization criteria

  • Continue to meet the standard Inflammatory Conditions – Simponi Subcutaneous Prior Authorization Policy criteria

Approval duration

1 year