Limited coverage drugs – golimumab
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| Generic name | Strength | Form |
|---|---|---|
| golimumab | 50 MG/0.5 ML | pen injector |
| golimumab | 50 MG/4 ML | I.V. vial |
| golimumab | 50 MG/0.5 ML | syringe |
|
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)
Log in to eForms or 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)
- 5354 - Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Rheumatoid Arthritis - Renewal (PDF)
- 5383 - Health Assessment Questionnaire (HAQ) (PDF)
Psoriatic Arthritis
- 5360 - Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis – Initial/Switch (PDF)
- 5361 - Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis - Renewal (PDF)
- 5364 - Bath Ankylosing Spondylitis - Disease Activity Index (BASDAI) (PDF)
- 5383 - Health Assessment Questionnaire (HAQ) (PDF)
Ankylosing Spondylitis:
