Simponi (golimumab) subcutaneous injection — Medical Mutual

Initial criteria

• Patient age ≥ 18 years
• Patient has tried one systemic therapy (e.g., 6-mercaptopurine, azathioprine, cyclosporine, tacrolimus, corticosteroid) OR has had a trial of one biologic other than the requested drug OR patient has pouchitis and has tried therapy with an antibiotic, probiotic, corticosteroid enema, or mesalamine enema
• Simponi is prescribed by or in consultation with a gastroenterologist
• 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 an improvement in at least one symptom (e.g., decreased pain, fatigue, stool frequency, decreased rectal bleeding)
• Site of care medical necessity is met

Approval duration

initial 6 months, reauth 1 year