Simponi subcutaneous — Medica

Initial criteria

• Patient meets the standard Inflammatory Conditions – Simponi Subcutaneous Prior Authorization Policy criteria; AND
• For Rheumatoid Arthritis: patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR [documentation required]; OR
• For Ankylosing Spondylitis: patient has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, or Xeljanz/XR [documentation required]; OR
• For Psoriatic Arthritis: patient has tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, Stelara subcutaneous, Taltz, Tremfya subcutaneous, or Xeljanz/XR [documentation required]; OR
• For Ulcerative Colitis: patient has tried one adalimumab product.

Approval duration

1 year