Policy

Network Health covers Simponi (golimumab) with prior authorization for Network Health Together^®, Network Health Forward^®, Network Health Extend^™, and Network Health Choice members who meet specific coverage criteria. Simponi is only available through our specialty pharmacy program as a pharmacy benefit.  

Covered conditions 

Network Health covers Simponi when a member meets all criteria for one of the following conditions:

Ankylosing spondylitis

• Is 18 years of age or older, and 
• Has been evaluated by a rheumatologist, and
• Has tried and failed treatment with or has a contraindication to one nonsteroidal anti-inflammatory drug (NSAID), and
• Has tried and failed treatment with another biological agent, such as Humira, Enbrel, or Remicade; or is a new Network Health member already stabilized on Simponi treatment

Psoriatic arthritis

• Is 18 years of age or older, and
• Has been evaluated by a rheumatologist or dermatologist, and 
• Has tried and failed treatment with or has a contraindication to one traditional disease-modifying antirheumatic drug (DMARD), such as azathioprine, gold therapy, hydroxycholoroquine, methotrexate, penicillamine, sulfasalazine, cyclosporine, or leflunomide, and
• Has tried and failed treatment with another biological agent, such as Humira, Enbrel, or Remicade; or is a new Network Health member already stabilized on Simponi treatment

Rheumatoid arthritis

• Is 18 years of age or older, and
• Has been evaluated by a rheumatologist, and
• Is currently taking methotrexate; or has tried and failed treatment with or has a contraindication to methotrexate and one other traditional DMARD, such as azathioprine, gold therapy, hydroxycholoroquine, penicillamine, sulfasalazine, cyclosporine, or leflunomide, and 
• Has tried and failed treatment with another biological agent, such as Orencia, Humira, Kineret, Cimzia, Enbrel, or Remicade; or is a new Network Health member already stabilized on Simponi treatment

Please note: Network Health will approve one year of initial Simponi treatment for any of the covered conditions described in the covered conditions section. Network Health will continue to approve Simponi treatment annually for these conditions when a provider provides clinical documentation (e.g., office note, specialist note) of member improvement while receiving Simponi. 

Noncovered conditions 

Network Health does not cover Simponi for conditions not described in the covered conditions section.

Definitions

Ankylosing spondylitis — a chronic inflammatory arthritis that affects the joints in the spine and the sacroilium in the pelvis. It causes the vertebrae in the spine to fuse eventually. 

Psoriatic arthritis — a form of rheumatoid arthritis associated with psoriasis that usually affects fingers and toes.

Rheumatoid arthritis — a chronic and progressive disease in which the immune system attacks the joints. This disease is characterized by pain, inflammation, and swelling of the joints; stiffness; weakness; loss of mobility; and deformity. 

Guidelines reference 

Menter, A., Gottlieb, A., Korman, N. J., Gordon, K. B., Feldman, S. R., Lebwohl, M., Koo, J. Y. M., Van Voorhees, A. S., Elmets, C. A., Leonardi, C. L, Beutner, K. R., & Bhushan, R. (2008). Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. Journal of the American Academy of Dermatology. 58 (5), 826 – 850.

Menter, A., Gottlieb, A., Korman, N. J., Gordon, K. B., Feldman, S. R., Lebwohl, M., Koo, J. Y. M., Van Voorhees, A. S., Elmets, C. A., Leonardi, C. L, Beutner, K. R., & Bhushan, R. (2008). Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: Overview and guidelines of care for the treatment with an emphasis on biologics. Journal of the American Academy of Dermatology. 58 (5), 851 – 864.

Saag, K. G, Teng, G. G., Patkar, N. M., Anuntiyo, J., Finney, C., Curtis, J. R., Paulus, H. E., Mudano, A., Pisu, M., Elkins-Melton, M., Outman, R., Allison, J. J., Almazor, M. S., Bridges, Jr., S. L., Chatham, W. W., Hochberg, M., MacLean, C., Mikuls, T., Moreland, L. W., O’Dell, J., Turkiewicz, A. M., & Furst, D. E. (2008). American College of Rheumatology 2008 recommendations for the use of nonbiological and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis & Rheumatism. 59 (6), 762 – 784.

Simponi [package insert]. (2009). Centocor Ortho Biotech, Inc.

Zochling, J., van der Heijde, D., Burgos-Vargas, R., Collantes, E., Davis, Jr., J. C., Dijkmans, B., Dougados, M., Géher, P., Inman, R. D., Khan, M. A., Kvien, T. K., Leirisalo-Repo, M., Olivieri, I., Pavelka, K., Sieper, J., Stucki, G., Sturrock, R. D., van der Linden, S., Wendling, D., Böhm, H., van Royen, B. J., & Braun, J. (2006.) ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis. 65, 442.

These guidelines apply to Network Health Together, Network Health Forward, Network Health Extend, and Network Health Choice plans. Coverage is based on member benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines by a provider does not guarantee coverage. Network Health reserves the right to amend these guidelines at its discretion. 03181