Golimumab (Simponi®)

SELF / OFFICE ADMINISTRATION

Indications for Prior Authorization:

  • Moderate to severe rheumatoid arthritis
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Ulcerative colitis

Patients must meet the following criteria for the indications above:

  • For approval for Rheumatoid Arthritis, patient must fail two of the following preferred:  Humira® AND/OR Enbrel® AND/OR Actemra® AND/OR Xeljanz/XR®.  
  • For approval for Ankylosing Spondylitis, patient must fail two of the following preferred:  Humira® AND/OR Enbrel® AND/OR Cosentyx®.
  • For approval for Psoriatic Arthritis, patient must fail two of the following preferred:  Humira® AND/OR Enbrel® AND/OR Stelara® AND/OR Cosentyx®, AND/OR Xeljanz/XR®.  
  • For approval for Ulcerative Colitis, patient must have tried and failed Humira® AND/OR Xeljanz®.
  • Failure is defined as patient not in remission OR has clinically significant adverse reaction to the preferred medication(s).  

Dosing:

Rheumatoid Arthritis

  • Golimumab is patient administered by subcutaneous injection (SubQ) 50 mg, once monthly

Ankylosing Spondylitis

  • Up to 50mg SubQ once a month

Psoriatic Arthritis

  • Up to 50mg SubQ once a month

Ulcerative Colitis

  • Self-inject 200mg SubQ initially, then 100mg SubQ at week two. Inject 100mg once a month for maintenance therapy

Approval:

  • Initial approval 3 months to assess patient’s response
  • Renew for one year if patient has clinical response

Risk of Tuberculosis and Serious Infection:

Patients should be evaluated for latent tuberculosis infection with a TB skin test. Treatment of latent tuberculosis infection should be initiated prior to therapy with golimumab

Do not administer live vaccines or attenuated vaccines concurrently with golimumab

Last review date: April 30, 2019