MedicaidPrior AuthMedium impact
Simponi ARIA (golimumab) (Revised)
Humana·SC · Rheumatology, Gastroenterology, Pediatrics·Medicaid
Effective date
Aug 27, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Simponi ARIA (golimumab) prior authorization policy for Medicaid in South Carolina, effective August 27, 2025. The policy maintains prior authorization requirements for four indications (ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis) with specific criteria for age, prior therapy, and contraindications. Key requirement: all indications prohibit combination therapy with other biologics, and rheumatoid arthritis patients must receive concomitant methotrexate unless contraindicated.
Action Required
By August 27, 2025: Billing and prior authorization teams must implement the revised Simponi ARIA policy requirements in the authorization system. (1) Verify all prior authorization requests for Simponi ARIA (J1602) meet the specific criteria for each indication: age thresholds (18+ for AS/RA, 2+ for PsA/pJIA), prior therapy/contraindication/intolerance documentation (NSAID for AS; NSAID + DMARD for PsA; DMARD for pJIA; DMARD for RA), and methotrexate requirement for RA unless documented contraindication/intolerance. (2) Implement system hard stops to deny authorization if members are concurrently on other biologics (Cosentyx, Enbrel, adalimumab, Kevzara, Remicade). (3) Update prior authorization forms and templates to require documentation of black box warning acknowledgment (serious infections, TB testing, malignancy risk). (4) Train prior authorization staff on the requirement that rheumatoid arthritis patients must be on concomitant methotrexate during golimumab therapy. (5) Notify in-network rheumatology and gastroenterology providers of the revised criteria. Failure to enforce these requirements will result in claim denials and payment recoupment.