Limited coverage drugs – golimumab

Covered golimumab forms and strengths

Generic name	Strength	Form
golimumab	50 mg/0.5 mL	pen injector
golimumab	50 mg/4 mL	IV vial
golimumab	50 mg/0.5 mL	syringe

SA criteria for golimumab

Special Authority criteria	Approval period
Treatment of rheumatoid arthritis according to established criteria* when requested by a rheumatologist	1 year
Treatment of psoriatic arthritis according to established criteria* when requested by a rheumatologist	1 year
Treatment of ankylosing spondylitis according to established criteria* when requested by a rheumatologist	1 year

*Established criteria is explained in the Special Authority forms linked below. 

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:

• 5365 - Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis – Initial/Switch (PDF)
• 5366 - Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis - Renewal (PDF)
• 5364 - Bath Ankylosing Spondylitis - Disease Activity Index (BASDAI) (PDF)