MedicaidPrior AuthHigh impact
Simponi ARIA (golimumab) (Revised)
Humana·SC · Rheumatology, Internal Medicine, Pediatrics·Medicaid
Effective date
Jan 1, 2019
We identified it
Jul 23, 2026
Summary
This is a revised Simponi ARIA (golimumab) prior authorization policy for Medicaid in South Carolina, effective January 1, 2019, with the most recent revision dated July 22, 2026. The policy outlines specific clinical criteria and exclusions for coverage across four indications: ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. Key requirements include prior NSAID/DMARD therapy, age restrictions, contraindications to combination biologic therapy, and mandatory methotrexate co-therapy for rheumatoid arthritis unless contraindicated.
Action Required
By January 1, 2026 (or immediately if not yet implemented): Billing and prior authorization teams must implement this policy for all Simponi ARIA (J1602) claims submitted for South Carolina Medicaid members. For each of the four approved indications, verify that: (1) Members meet ALL applicable clinical criteria before authorizing claims; (2) Members do NOT meet any exclusion criteria (particularly no concurrent biologic use); (3) For rheumatoid arthritis specifically, ensure members are on concomitant methotrexate unless contraindicated; (4) Prior therapy/contraindication/intolerance documentation is obtained from providers before submission. Update prior authorization workflows in billing software to flag missing clinical documentation. Train billing staff on age restrictions (18+ for ankylosing spondylitis and rheumatoid arthritis; 2+ for psoriatic arthritis and juvenile idiopathic arthritis). Establish denial protocol for claims lacking required prior therapy documentation or showing biologic combinations. Communicate policy requirements to all prescribing providers in your network. Failure to obtain proper prior authorization will result in claim denials for South Carolina Medicaid patients.