Simponi (golimumab) subcutaneous injection — Medical Mutual

Initial criteria

• Patient age ≥ 18 years
• Patient has arthritis primarily in knees, ankles, elbows, wrists, hands, and/or feet AND has tried at least one conventional synthetic DMARD OR patient has axial spondyloarthritis with objective signs of inflammation (CRP elevated beyond ULN OR sacroiliitis on MRI)
• Simponi is prescribed by or in consultation with a rheumatologist
• Site of care medical necessity is met

Reauthorization criteria

• Patient has been established on therapy for at least 6 months
• When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline OR compared with baseline patient experienced improvement in at least one symptom (e.g., decreased pain, stiffness, improved function, activities of daily living)
• Site of care medical necessity is met

Approval duration

initial 6 months, reauth 1 year