Limited Coverage Drugs - Golimumab

Generic Name / Strength / Form

golimumab (Simponi®)

Special Authority Criteria

Approval Period

1. Treatment of Rheumatoid Arthritis according to established criteria* when prescribed by a rheumatologist 1 year
2. Treatment of Psoriatic Arthritis according to established criteria* when prescribed by a rheumatologist 1 year
3. Treatment of Ankylosing Spondylitis according to established criteria* when prescribed by a rheumatologist 1 year

Practitioner Exemptions

  • None

Special Notes

  • For coverage, the maximum allowable supply of golimumab is one month of medication per fill.

Special Authority Request Form(s)

* Click on the appropriate Special Authority Form below for full criteria:

Rheumatoid Arthritis

Psoriatic Arthritis

Ankylosing Spondylitis: