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
- 5345 - Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Rheumatoid Arthritis - Initial/Switch (PDF, 333KB)
- 5354 - Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Rheumatoid Arthritis - Renewal (PDF, 315KB)
- 5383 - Health Assessment Questionnaire (HAQ) (PDF, 526KB)
Psoriatic Arthritis
- 5360 - Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis – Initial/Switch (PDF, 222KB)
- 5361 - Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis - Renewal (PDF, 188KB)
- 5364 - Bath Ankylosing Spondylitis - Disease Activity Index (BASDAI) (PDF, 72KB)
- 5383 - Health Assessment Questionnaire (HAQ) (PDF, 526KB)
Ankylosing Spondylitis:
