Simponi (golimumab) — United Healthcare

Initial criteria

• Diagnosis of moderately to severely active ulcerative colitis
• One of the following: (a) Patient is corticosteroid dependent (inability to successfully taper corticosteroids without recurrence of UC symptoms) OR (b) History of inadequate response or failure to tolerate one of the following: oral aminosalicylates, oral corticosteroids, azathioprine, or 6‑mercaptopurine
• Patient is not receiving Simponi in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib)]

Reauthorization criteria

• Documentation of positive clinical response to Simponi therapy
• Patient is not receiving Simponi in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib)]

Approval duration

12 months