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AetnaCommercial · Prior Auth · Medical Policy · Rheumatology, Gastroenterology, Dermatology +3 moreMedium impact

Golimumab (Simponi and Simponi Aria) (CPB 0790, reviewed 2026-07-31)

Effective date
Not stated in the notice
Identified
Aug 15, 2026

Summary

Golimumab is covered for commercial plans when the criteria for the requested form and indication are met. Intravenous Simponi Aria is covered for moderately to severely active rheumatoid arthritis given with methotrexate, active psoriatic arthritis, active ankylosing spondylitis, articular juvenile idiopathic arthritis in members 2 years of age or older, and moderate or severe immune checkpoint inhibitor-related inflammatory arthritis. Subcutaneous Simponi is covered for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, moderately to severely active ulcerative colitis, and immune checkpoint inhibitor-related inflammatory arthritis. Concomitant use with another biologic or targeted synthetic drug for the same indication is considered experimental, investigational or unproven, as are Behcet's disease, Crohn's disease, non-infectious uveitis, panuveitis, posterior uveitis and scleritis for intravenous golimumab, plus asthma and sarcoidosis for subcutaneous golimumab.

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What to do

Action · 13 steps
01Billing team: Simponi Aria requires precertification.
02Obtain it by calling (866) 752-7021 or faxing (888) 267-3277, and use the Statement of Medical Necessity forms in the Specialty Pharmacy Precertification section.
03For commercial plans, the Site of Care Utilization Management Policy applies to Simponi Aria, so follow the Site of Care for Specialty Drug Infusions policy for infusion site requirements.
04Bill intravenous Simponi Aria under HCPCS J1602, which is for Simponi Aria only, since there is no specific code for subcutaneous Simponi.
05Document in the medical record the criteria each request relies on.
06For rheumatoid arthritis, this includes a positive rheumatoid factor or anti-CCP test (or all of RF, anti-CCP, and CRP and/or ESR), the methotrexate, hydroxychloroquine, sulfasalazine or leflunomide trial results, and the disease activity level.
07For continuation of therapy, document improvement of at least 20% from baseline in tender joint count, swollen joint count, pain or disability.
08For biologic-naive members, document a negative tuberculosis test (skin test or IGRA) within 12 months of starting therapy.
09Confirm the prescriber is a rheumatologist, dermatologist (psoriatic arthritis), gastroenterologist (subcutaneous ulcerative colitis), or oncologist, hematologist or rheumatologist (immune checkpoint inhibitor-related toxicity).
10Do not bill the requested medication together with any other biologic drug or targeted synthetic drug for the same indication.
11Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia and evidence-based practice guidelines, see Medical Specialty Medication Quantity Limits.
12Intravenous Simponi Aria dosing is 2 mg/kg over 30 minutes at weeks 0 and 4, then every 8 weeks.
13Subcutaneous Simponi dosing for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis is 50 mg once a month.

Codes mentioned

J1602L40.50L40.59M05.00M06.9M08.00M08.99M08.1M13.80M13.89M45.0M45.ABK51.00K51.919T45.AX5AT45AX5S

Original notice

Golimumab (Simponi and Simponi Aria) (CPB 0790, reviewed 2026-07-31)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesRheumatologyGastroenterologyDermatologyOncologyHematologyPediatricsCode J1602Code L40.50Code L40.59Code M05.00Code M06.9Code M08.00Code M08.99Code M08.1Code M13.80Code M13.89Code M45.0Code M45.ABCode K51.00Code K51.919Code T45.AX5ACode T45AX5S

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