Golimumab (Simponi Aria®)

Restricted Product(s)

• golimumab (Simponi Aria®) intravenous infusion for administration by a healthcare professional

FDA Approved Use

• For adult patients with moderately to severely active rheumatoid arthritis, in combination with methotrexate 
• For patients 2 years and older with active psoriatic arthritis 
• For adult patients with active ankylosing spondylitis 
• For patients 2 years and older with active polyarticular juvenile idiopathic arthritis

Criteria for Medical Necessity

The restricted product(s) may be considered medically necessary when the following criteria are met:

1. The patient has a diagnosis of moderately to severely active rheumatoid arthritis (RA); AND 
   1. The patient is 18 years of age or older; AND 
   2. The patient has tried and had an inadequate response to maximally tolerated methotrexate (e.g., titrated to 25 mg weekly) for at least 3-months [medical record documentation required]; OR 
   3. The patient has tried and had an inadequate response to another conventional agent (i.e., hydroxychloroquine, leflunomide, sulfasalazine) used in the treatment of RA for at least 3-months [medical record documentation required]; OR 
   4. The patient has an intolerance or hypersensitivity to ONE of the following conventional agents (i.e., maximally tolerated methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) used in the treatment of RA [medical record documentation required]; OR 
   5. The patient has an FDA labeled contraindication to ALL of the following conventional agents (i.e., methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) used in the treatment of RA [medical record documentation required]; AND 
   6. The patient will be taking the requested agent in combination with methotrexate; OR 
   7. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to methotrexate [medical record documentation required]; OR 
2. The patient has a diagnosis of active psoriatic arthritis (PsA); AND 
   1. The patient is 2 years of age or older; AND
   2. The patient has tried and had an inadequate response to ONE conventional agent (i.e., cyclosporine, leflunomide, methotrexate, sulfasalazine) used in the treatment of PsA for at least 3-months [medical record documentation required]; OR 
   3. The patient has an intolerance or hypersensitivity to ONE of the conventional agents used in the treatment of PsA [medical record documentation required]; OR 
   4. The patient has an FDA labeled contraindication to ALL of the conventional agents used in the treatment of PsA [medical record documentation required]; OR 
   5. The patient has severe active PsA (e.g., erosive disease, elevated markers of inflammation [e.g., ESR, CRP] attributable to PsA, long-term damage that interferes with function [i.e., joint deformities], rapidly progressive) [medical record documentation required]; OR 
   6. The patient has concomitant severe psoriasis (PS) (e.g., greater than 10% body surface area involvement, occurring on select locations [i.e., hands, feet, scalp, face, or genitals], intractable pruritus, serious emotional consequences) [medical record documentation required]; OR
3. The patient has a diagnosis of active ankylosing spondylitis (AS); AND
   1. The patient is 18 years of age or older; AND 
   2. The patient has tried and had an inadequate response to two different NSAIDs used in the treatment of AS for at least a 4-week total trial [medical record documentation required]; OR 
   3. The patient has an intolerance or hypersensitivity to two different NSAIDs used in the treatment of AS [medical record documentation required]; OR 
   4. The patient has an FDA labeled contraindication to ALL NSAIDs used in the treatment of AS [medical record documentation required]; OR 
4. The patient has a diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis (PJIA); AND
   1. The patient is 2 years of age or older; AND 
   2. The patient has tried and had an inadequate response to ONE conventional agent (i.e., methotrexate, leflunomide) used in the treatment of PJIA for at least 3-months [medical record documentation required]; OR 
   3. The patient has an intolerance or hypersensitivity to ONE of the conventional agents used in the treatment of PJIA [medical record documentation required]; OR 
   4. The patient has an FDA labeled contraindication to ALL of the conventional agents used in the treatment of PJIA [medical record documentation required]; AND 
5. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., rheumatologist for RA, PsA, AS, JIA) or has consulted with a specialist in the area of the patient’s diagnosis; AND
6. The patient will NOT be using golimumab (Simponi Aria®) in combination with another biologic immunomodulator agent or Otezla®; AND 
7. The patient does NOT have any FDA labeled contraindications to golimumab (Simponi Aria®); AND 
8. The patient has been tested for latent tuberculosis (TB) when required by the prescribing information for the requested agent AND if positive the patient has begun therapy for latent TB; AND 
9. The requested quantity does NOT exceed the maximum units allowed for the duration of approval (see table below); AND 
10. For requests for injection or infusion administration of the requested medication in an inpatient or outpatient hospital setting, Site of Care Criteria applies (outlined below)*
    
    Duration of Approval: 365 days (1 year)

*Site of Care Medical Necessity Criteria

1. For requests for injection or infusion administration in an inpatient setting, the injection or infusion may be given if the above medical necessity criteria are met AND the inpatient admission is NOT for the sole purpose of administering the injection or infusion; OR 
2. For requests for injection or infusion administration in an outpatient hospital setting, the injection or infusion may be given if the above medical necessity criteria are met AND ONE of the following must be met: 
   1. History of mild adverse events that have not been successfully managed through mild pre-medication (e.g., diphenhydramine, acetaminophen, steroids, fluids, etc.); OR 
   2. Inability to physically and cognitively adhere to the treatment schedule and regimen complexity; OR 
   3. New to therapy, defined as initial injection or infusion OR less than 3 months since initial injection or infusion; OR 
   4. Re-initiation of therapy, defined as ONE of the following:
      1. First injection or infusion after 6 months of no injections or infusions for drugs with an approved dosing interval less than 6 months duration; OR 
      2. First injection or infusion after at least a 1-month gap in therapy outside of the approved dosing interval for drugs requiring every 6 months dosing duration; OR 
   5. Requirement of a change in the requested restricted product formulation; AND 
3. If the Site of Care Medical Necessity Criteria in #1 or #2 above are not met, the injection or infusion will be administered in a home-based infusion or physician office setting with or without supervision by a certified healthcare professional. 

References

All information referenced is from FDA package insert unless otherwise noted below.

1. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care & Research. 2021;73(7):924-39.

Policy Implementation/Update Information

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q1 annually.

September 2023: Criteria change: For PsA: Removed hydroxychloroquine from list of conventional agents. For PJIA: Adjusted list of tried and failed conventional agents. Separated out intolerance/hypersensitivity criteria from FDA labeled contraindication criteria for clarity. Updated FDA label reference label for clarity according to FDA label. Updated references.
August 2021: Criteria change: Removed criteria points regarding medication history indicating use of another biologic immunomodulator agent FDA labeled for the treatment of the same condition. Policy notification given 6/1/2021 for effective date 8/1/2021.
June 2021: Criteria change: Medical record documentation required for all indications.
April 2021: Criteria change: Addition of criteria for history of use of another biologic immunomodulator agent (or Otezla) for the same indication; RA: added option for trial of another conventional agent, added requirement to be taken in combination with methotrexate; PsA: added requirement for trial of one conventional agent, added option for severe active PsA or concomitant severe psoriasis; AS: added requirement for trial of two different NSAIDs or intolerance/contraindication/hypersensitivity to all NSAIDs; PJIA: added requirement for trial of one conventional agent; added requirements to be prescribed by or in consultation with a specialist, that patient has no FDA labeled contraindications, and for TB testing; added maximum units; medical policy formatting change. Policy notification given 2/26/2021 for effective date 4/28/2021.
*Further historical criteria changes and updates available upon request from Medical Policy and/or Corporate Pharmacy