Limited coverage criteria – golimumab
Last updated on March 18, 2025
Return to Special Authority drug list
Generic name |
golimumab |
|---|---|
Strength |
Form |
| 50 mg/0.5 mL | pen injector |
| 50 mg/4 mL | IV vial |
| 50 mg/0.5 mL | syringe |
Special Authority criteria |
Approval period |
|---|---|
|
Treatment of rheumatoid arthritis according to established criteria* when requested by a rheumatologist OR Treatment of psoriatic arthritis according to established criteria* when requested by a rheumatologist OR 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.
Rheumatoid arthritis
- 5345 – Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Rheumatoid Arthritis - Initial/Switch (PDF, 869KB)
- 5354 – Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Rheumatoid Arthritis - Renewal (PDF, 893KB)
- 5383 – Health Assessment Questionnaire (HAQ) (PDF, 528KB)
Psoriatic arthritis
- 5360 – Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis – Initial/Switch (PDF, 839KB)
- 5361 – Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis - Renewal (PDF, 831KB)
- 5364 – Bath Ankylosing Spondylitis - Disease Activity Index (BASDAI) (PDF, 64KB)
- 5383 – Health Assessment Questionnaire (HAQ) (PDF, 528KB)
Ankylosing spondylitis