Simponi® and Simponi Aria® (golimumab)

Authorization forms

(forms cover both subcutaneous Simponi and IV Simponi Aria)

Traditional & Optimized (01/2019)

Medicare Part D (01/2019)

Simponi Aria:

Medicaid (07/2019)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J1602

Benefit: Medical or Pharmacy

Notes: Treatment of Ankylosing spondylitis, Psoriatic arthritis and Rheumatoid arthritis