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

By July 31, 2026: (1) Billing team must implement precertification workflow for all intravenous golimumab (Simponi Aria) requests by calling (866) 752-7021 or faxing (888) 267-3277; (2) Update billing system to enforce prescriber specialty requirements—rheumatologist for RA/AS/nr-axSpA/JIA, rheumatologist or dermatologist for PsA, oncologist/hematologist/rheumatologist for checkpoint inhibitor toxicity; (3) Create clinical criteria checklist in billing software to verify prior therapy trials, biomarker testing (RF, anti-CCP, CRP/ESR), and documented disease activity before claim submission; (4) For RA cases, ensure documentation of either prior biologic/targeted synthetic drug use OR completion of required DMARD trial periods (minimum 3 months) with dose validation; (5) Apply site-of-care utilization management policy to Simponi Aria infusions per separate UM policy; (6) For all non-initial therapy claims, verify documented clinical response showing disease activity improvement of at least 20% before approving continuation. Claims submitted without required precertification, specialty verification, or clinical criteria documentation will be denied. Front desk staff must route all golimumab requests to precertification team immediately upon receipt.