Medicare AdvantagePrior AuthHigh impact
Simponi (golimumab) (Revised)
Humana·Rheumatology, Gastroenterology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 23, 2026
Summary
Humana has revised its Simponi (golimumab) pharmacy coverage policy for Medicare Advantage members, effective January 1, 2026, with a July 22, 2026 revision. The policy establishes prior authorization requirements for Simponi across four indications (Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, and Ulcerative Colitis) with updated criteria requiring prior failure/contraindication/intolerance to specific biologic therapies before approval.
Action Required
By January 1, 2026: Billing and prior authorization teams must implement this revised policy for all Medicare Advantage members. Update billing system and prior auth software to require documentation of prior therapy, contraindication, or intolerance to two of the specified biologics (varies by indication) before approving Simponi claims. For Rheumatoid Arthritis: require failure/contraindication/intolerance to two of Humira/adalimumab biosimilars, Enbrel, or Rinvoq, PLUS concomitant methotrexate documentation. For Psoriatic Arthritis: require two of Humira/biosimilars, Enbrel, Cosentyx, Stelara/ustekinumab biosimilars, Skyrizi, Rinvoq, or Tremfya. For Ankylosing Spondylitis: require two of Humira/biosimilars, Enbrel, Cosentyx, or Rinvoq. For Ulcerative Colitis: require weight ≥15 kg and two of Humira/biosimilars, Stelara/ustekinumab biosimilars, Skyrizi, Rinvoq, or Tremfya. Providers must include step-therapy documentation with all Simponi prior authorization requests. Claims submitted without documented step-therapy will be denied. Front desk staff should alert providers to updated requirements during pre-authorization screening.