1. No category

DRUG POLICY
Simponi® Aria™ (golimumab)
Policy Number: 2015D0051A
Effective Date: 3/1/2015
Table of Contents
Page
COVERAGE RATIONALE ................................................. 1
BENEFIT CONSIDERATIONS .......................................... 2
BACKGROUND ................................................................. 2
CLINICAL EVIDENCE ....................................................... 2
U.S. FOOD AND DRUG ADMINISTRATION .................... 3
APPLICABLE CODES ....................................................... 3
REFERENCES ................................................................. 10
POLICY HISTORY/REVISION INFORMATION .............. 10
Related Medical or
Drug Policies:
None
COV
ERA
GE
RATI
ONA
LE
Related Coverage
Determination
Guidelines:
None
INSTRUCTIONS FOR USE
This Drug Policy provides assistance in interpreting UnitedHealthcare benefit plans. When deciding
coverage, the enrollee specific document must be referenced. The terms of an enrollee's document (e.g.,
Certificate of Coverage (COC) or Summary Plan Description (SPD)) may differ greatly. In the event of a
conflict, the enrollee's specific benefit document supersedes this Drug Policy. All reviewers must first
identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage prior
to use of this Drug Policy. Other Policies and Coverage Determination Guidelines may apply.
UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines as
necessary. This Drug Policy is provided for informational purposes. It does not constitute medical advice.
UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to
assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in
connection with the independent professional medical judgment of a qualified health care provider and do
not constitute the practice of medicine or medical advice.
COVERAGE RATIONALE
Golimumab is proven and medically necessary for the treatment of rheumatoid arthritis.
1
Medicare covers outpatient (Part B) drugs that are furnished “incident to” a physician’s service provided
that the drugs are not usually self-administered by the patients who take them. See the Medicare Benefit
Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals at
http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.
®
™
Medicare does not have a National Coverage Determination (NCD) for Simponi ARIA (golimumab).
Local Coverage Determinations (LCDs) do not exist at this time.
(Accessed September 30, 2014)
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
1
Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
BENEFIT CONSIDERATIONS
Some Certificates of Coverage allow coverage of experimental/investigational/unproven treatments for
life-threatening illnesses when certain conditions are met. The enrollee-specific benefit document must be
consulted to make coverage decisions for this service. Some states mandate benefit coverage for offlabel use of medications for some diagnoses or under some circumstances when certain conditions are
met. Where such mandates apply, they supersede language in the benefit document or in the medical or
drug policy. Benefit coverage for an otherwise unproven service for the treatment of serious rare diseases
may occur when certain conditions are met. See the Policy and Procedure addressing the treatment of
serious rare diseases.
BACKGROUND
Golimumab is a human anti-tumor necrosis factor (TNF) monoclonal antibody that targets both soluble
and transmembrane bioactive forms of TNF-alpha, a protein that when overproduced in the body due to
1
chronic inflammatory diseases can cause inflammation and damage to bones, cartilage and tissue.
CLINICAL EVIDENCE
The efficacy of intravenous golimumab in combination with methotrexate (MTX) was evaluated in a
multicenter, double-blind, placebo-controlled, phase 3 study of patients (n=592) with active rheumatoid
2
arthritis (RA) who had been receiving MTX. All subjects had active disease defined as ≥ 6 swollen joints,
≥ 6 tender joints, C-reactive protein ≥1.0 mg/dL, rheumatoid factor positive, and/or anticyclic citrullinated
protein antibody positive at screening despite MTX (15–25 mg/week). Study subjects were treatment
naive to biologic tissue necrosis factor (TNF) blockers and were allowed to continue stable doses of
concomitant low-dose corticosteroids (not exceeding equivalent prednisone 10 mg/day) and NSAIDs.
Participants were randomized to receive intravenous golimumab 2 mg/kg (n=395) or placebo (n=197)
infusions at weeks 0 and 4, and every 8 weeks thereafter through Week 100 while continuing to receive
MTX. Patients in the placebo group with <10% improvement in combined swollen/tender joint counts at
week 16 were allowed early escape to intravenous golimumab 2 mg/kg. By week 24, all patients were
switched to golimumab and MTX, but remained blinded until week 52. The primary endpoint was American
College of Rheumatology 20% (ACR20) Response at Week 14. Other measures of disease activity included
the European League Against Rheumatism (EULAR) response and Health Assessment Questionnaire (HAQ).
Improvements in the study group versus the placebo group were observed by week 2. At week 14,
significantly (p<0.001) larger proportions of golimumab plus MTX than placebo plus MTX patients
achieved ACR20 response (59% vs 25%, respectively; treatment difference, 95% CI, 25.9% to 41.4%).
Additionally, a greater proportion of patients in the study group achieved an ACR50 at week 24 (35% vs
13%; treatment difference, 95% CI, 15.5% to 28.4%). A disease activity score of good/moderate (EULAR)
response (81% vs 40%) and greater median improvement in health assessment questionnaire scores
(0.500 vs 0.125) were seen. Similar proportions of patients receiving golimumab plus MTX and placebo
plus MTX, respectively, reported adverse events through week 16 (47% and 44%) and week 24 (53% and
49%). Serious adverse events were reported by more golimumab plus MTX (4.1%) than placebo plus MTX
(2%) patients at week 24.
Professional Societies
The 2012 Update of the 2008 American College of Rheumatology (ACR) recommendations includes
golimumab as part of the anti-TNF biologic class along with adalimumab, etanercept, infliximab, and
4
certolizumab pegol. The update says the following regarding the treatment of rheumatoid arthritis (RA):
• In patients with early RA (disease duration < 6 months), the panel recommends the use of an antiTNF biologic with or without methotrexate in patients who have high disease activity with poor
prognostic features. Infliximab is the only exception and the recommendation is to use it in
combination with methotrexate, but not as monotherapy.
• In patients with established RA (disease duration greater than or equal to 6 months or meeting the
1987 ACR classification criteria):
o If a patient has moderate or high disease activity after 3 months of methotrexate
monotherapy or DMARD combination therapy, as an alternative to the DMARD
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
2
Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
o
o
o
o
o
recommendation just noted above, the panel recommends adding or switching to an anti-TNF
biologic, abatacept, or rituximab.
If after 3 months of intensified DMARD combination therapy or after a second DMARD, a
patient still has moderate or high disease activity, add or switch to an anti-TNF biologic.
If a patient still has moderate or high disease activity after 3 months of anti-TNF biologic
therapy and this is due to a lack or loss of benefit, switching to another anti-TNF biologic or a
non-TNF biologic is recommended.
If a patient still has moderate or high disease activity after 6 months of a non-TNF biologic
and the failure is due to a lack or loss of benefit, switch to another non-TNF biologic or an
anti-TNF biologic.
If a patient has high disease activity after failing an anti-TNF biologic because of a serious
adverse event, switch to a non-TNF biologic.
If a patient has moderate or high disease activity after failing an anti-TNF biologic because of
a nonserious adverse event, switch to another anti-TNF biologic or a non-TNF biologic. If a
patient has moderate or high disease activity after failing a non-TNF biologic because of an
adverse event (serious or nonserious), switch to another non-TNF biologic or an anti-TNF
biologic.
U.S. FOOD AND DRUG ADMINISTRATION (FDA)
Simponi Aria, in combination with methotrexate, is indicated for the treatment of adult patients with
1
moderately to severely active rheumatoid arthritis (RA).
APPLICABLE CODES
The [Current Procedural Terminology (CPT), HCPCS and/or ICD-9] codes listed in this policy are for
reference purposes only. Listing of a service or device code in this policy does not imply that the service
described by this code is a covered or non-covered health service. Coverage is determined by the benefit
document.
HCPCS Code
J1602
ICD-9 Code
714.0
714.1
714.2
Description
Injection, golimumab, 1 mg, for intravenous use
Description
Rheumatoid arthritis
Felty’s Syndrome
Other rheumatoid arthritis, with visceral or systemic involvement
ICD-10 Codes (Preview Draft)
*
In preparation for the transition from ICD-9 to ICD-10 medical coding on October 1, 2015 , a sample
listing of the ICD-10 CM and/or ICD-10 PCS codes associated with this policy has been provided below
for your reference. This list of codes may not be all inclusive and will be updated to reflect any applicable
revisions to the ICD-10 code set and/or clinical guidelines outlined in this policy. *The effective date for
ICD-10 code set implementation is subject to change.
ICD-10 Diagnosis Code
(Effective 10/1/15)
M05.00
M05.011
M05.012
M05.019
M05.021
M05.022
M05.029
M05.031
M05.032
M05.039
Description
Felty's syndrome, unspecified site
Felty's syndrome, right shoulder
Felty's syndrome, left shoulder
Felty's syndrome, unspecified shoulder
Felty's syndrome, right elbow
Felty's syndrome, left elbow
Felty's syndrome, unspecified elbow
Felty's syndrome, right wrist
Felty's syndrome, left wrist
Felty's syndrome, unspecified wrist
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
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Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
M05.041
M05.042
M05.049
M05.051
M05.052
M05.059
M05.061
M05.062
M05.069
M05.071
M05.072
M05.079
M05.09
M05.20
M05.211
M05.212
M05.219
M05.221
M05.222
M05.229
M05.231
M05.232
M05.239
M05.241
M05.242
M05.249
M05.251
M05.252
M05.259
M05.261
M05.262
M05.269
M05.271
M05.272
M05.279
M05.29
M05.30
M05.311
M05.312
M05.319
M05.321
M05.322
M05.329
M05.331
M05.332
M05.339
M05.341
M05.342
M05.349
Felty's syndrome, right hand
Felty's syndrome, left hand
Felty's syndrome, unspecified hand
Felty's syndrome, right hip
Felty's syndrome, left hip
Felty's syndrome, unspecified hip
Felty's syndrome, right knee
Felty's syndrome, left knee
Felty's syndrome, unspecified knee
Felty's syndrome, right ankle and foot
Felty's syndrome, left ankle and foot
Felty's syndrome, unspecified ankle and foot
Felty's syndrome, multiple sites
Rheumatoid vasculitis with rheumatoid arthritis of unspecified site
Rheumatoid vasculitis with rheumatoid arthritis of right shoulder
Rheumatoid vasculitis with rheumatoid arthritis of left shoulder
Rheumatoid vasculitis with rheumatoid arthritis of unspecified
shoulder
Rheumatoid vasculitis with rheumatoid arthritis of right elbow
Rheumatoid vasculitis with rheumatoid arthritis of left elbow
Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow
Rheumatoid vasculitis with rheumatoid arthritis of right wrist
Rheumatoid vasculitis with rheumatoid arthritis of left wrist
Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist
Rheumatoid vasculitis with rheumatoid arthritis of right hand
Rheumatoid vasculitis with rheumatoid arthritis of left hand
Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand
Rheumatoid vasculitis with rheumatoid arthritis of right hip
Rheumatoid vasculitis with rheumatoid arthritis of left hip
Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip
Rheumatoid vasculitis with rheumatoid arthritis of right knee
Rheumatoid vasculitis with rheumatoid arthritis of left knee
Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee
Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot
Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot
Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle
and foot
Rheumatoid vasculitis with rheumatoid arthritis of multiple sites
Rheumatoid heart disease with rheumatoid arthritis of unspecified site
Rheumatoid heart disease with rheumatoid arthritis of right shoulder
Rheumatoid heart disease with rheumatoid arthritis of left shoulder
Rheumatoid heart disease with rheumatoid arthritis of unspecified
shoulder
Rheumatoid heart disease with rheumatoid arthritis of right elbow
Rheumatoid heart disease with rheumatoid arthritis of left elbow
Rheumatoid heart disease with rheumatoid arthritis of unspecified
elbow
Rheumatoid heart disease with rheumatoid arthritis of right wrist
Rheumatoid heart disease with rheumatoid arthritis of left wrist
Rheumatoid heart disease with rheumatoid arthritis of unspecified
wrist
Rheumatoid heart disease with rheumatoid arthritis of right hand
Rheumatoid heart disease with rheumatoid arthritis of left hand
Rheumatoid heart disease with rheumatoid arthritis of unspecified
hand
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
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Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
M05.351
M05.352
M05.359
M05.361
M05.362
M05.369
M05.371
M05.372
M05.379
M05.39
M05.40
M05.411
M05.412
M05.419
M05.421
M05.422
M05.429
M05.431
M05.432
M05.439
M05.441
M05.442
M05.449
M05.451
M05.452
M05.459
M05.461
M05.462
M05.469
M05.471
M05.472
M05.479
M05.49
M05.50
M05.511
M05.512
M05.519
M05.521
M05.522
M05.529
M05.531
M05.532
M05.539
M05.541
M05.542
Rheumatoid heart disease with rheumatoid arthritis of right hip
Rheumatoid heart disease with rheumatoid arthritis of left hip
Rheumatoid heart disease with rheumatoid arthritis of unspecified hip
Rheumatoid heart disease with rheumatoid arthritis of right knee
Rheumatoid heart disease with rheumatoid arthritis of left knee
Rheumatoid heart disease with rheumatoid arthritis of unspecified
knee
Rheumatoid heart disease with rheumatoid arthritis of right ankle and
foot
Rheumatoid heart disease with rheumatoid arthritis of left ankle and
foot
Rheumatoid heart disease with rheumatoid arthritis of unspecified
ankle and foot
Rheumatoid heart disease with rheumatoid arthritis of multiple sites
Rheumatoid myopathy with rheumatoid arthritis of unspecified site
Rheumatoid myopathy with rheumatoid arthritis of right shoulder
Rheumatoid myopathy with rheumatoid arthritis of left shoulder
Rheumatoid myopathy with rheumatoid arthritis of unspecified
shoulder
Rheumatoid myopathy with rheumatoid arthritis of right elbow
Rheumatoid myopathy with rheumatoid arthritis of left elbow
Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow
Rheumatoid myopathy with rheumatoid arthritis of right wrist
Rheumatoid myopathy with rheumatoid arthritis of left wrist
Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist
Rheumatoid myopathy with rheumatoid arthritis of right hand
Rheumatoid myopathy with rheumatoid arthritis of left hand
Rheumatoid myopathy with rheumatoid arthritis of unspecified hand
Rheumatoid myopathy with rheumatoid arthritis of right hip
Rheumatoid myopathy with rheumatoid arthritis of left hip
Rheumatoid myopathy with rheumatoid arthritis of unspecified hip
Rheumatoid myopathy with rheumatoid arthritis of right knee
Rheumatoid myopathy with rheumatoid arthritis of left knee
Rheumatoid myopathy with rheumatoid arthritis of unspecified knee
Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle
and foot
Rheumatoid myopathy with rheumatoid arthritis of multiple sites
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified
site
Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified
shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified
elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified
wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
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Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
M05.549
M05.551
M05.552
M05.559
M05.561
M05.562
M05.569
M05.571
M05.572
M05.579
M05.59
M05.60
M05.611
M05.612
M05.619
M05.621
M05.622
M05.629
M05.631
M05.632
M05.639
M05.641
M05.642
M05.649
M05.651
M05.652
M05.659
M05.661
M05.662
M05.669
M05.671
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified
hand
Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified
hip
Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified
knee
Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle
and foot
Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and
foot
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified
ankle and foot
Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
Rheumatoid arthritis of unspecified site with involvement of other
organs and systems
Rheumatoid arthritis of right shoulder with involvement of other
organs and systems
Rheumatoid arthritis of left shoulder with involvement of other organs
and systems
Rheumatoid arthritis of unspecified shoulder with involvement of other
organs and systems
Rheumatoid arthritis of right elbow with involvement of other organs
and systems
Rheumatoid arthritis of left elbow with involvement of other organs
and systems
Rheumatoid arthritis of unspecified elbow with involvement of other
organs and systems
Rheumatoid arthritis of right wrist with involvement of other organs
and systems
Rheumatoid arthritis of left wrist with involvement of other organs and
systems
Rheumatoid arthritis of unspecified wrist with involvement of other
organs and systems
Rheumatoid arthritis of right hand with involvement of other organs
and systems
Rheumatoid arthritis of left hand with involvement of other organs and
systems
Rheumatoid arthritis of unspecified hand with involvement of other
organs and systems
Rheumatoid arthritis of right hip with involvement of other organs and
systems
Rheumatoid arthritis of left hip with involvement of other organs and
systems
Rheumatoid arthritis of unspecified hip with involvement of other
organs and systems
Rheumatoid arthritis of right knee with involvement of other organs
and systems
Rheumatoid arthritis of left knee with involvement of other organs and
systems
Rheumatoid arthritis of unspecified knee with involvement of other
organs and systems
Rheumatoid arthritis of right ankle and foot with involvement of other
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
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Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
M05.672
M05.679
M05.69
M05.70
M05.711
M05.712
M05.719
M05.721
M05.722
M05.729
M05.731
M05.732
M05.739
M05.741
M05.742
M05.749
M05.751
M05.752
M05.759
M05.761
M05.762
M05.769
M05.771
M05.772
M05.779
M05.79
M05.80
M05.811
M05.812
organs and systems
Rheumatoid arthritis of left ankle and foot with involvement of other
organs and systems
Rheumatoid arthritis of unspecified ankle and foot with involvement of
other organs and systems
Rheumatoid arthritis of multiple sites with involvement of other organs
and systems
Rheumatoid arthritis with rheumatoid factor of unspecified site without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right shoulder without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left shoulder without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of unspecified shoulder
without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right elbow without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left elbow without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of unspecified elbow
without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right wrist without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left wrist without organ
or systems involvement
Rheumatoid arthritis with rheumatoid factor of unspecified wrist
without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right hand without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left hand without organ
or systems involvement
Rheumatoid arthritis with rheumatoid factor of unspecified hand
without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right hip without organ
or systems involvement
Rheumatoid arthritis with rheumatoid factor of left hip without organ or
systems involvement
Rheumatoid arthritis with rheumatoid factor of unspecified hip without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right knee without
organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left knee without organ
or systems involvement
Rheumatoid arthritis with rheumatoid factor of unspecified knee
without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of right ankle and foot
without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of left ankle and foot
without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of unspecified ankle and
foot without organ or systems involvement
Rheumatoid arthritis with rheumatoid factor of multiple sites without
organ or systems involvement
Other rheumatoid arthritis with rheumatoid factor of unspecified site
Other rheumatoid arthritis with rheumatoid factor of right shoulder
Other rheumatoid arthritis with rheumatoid factor of left shoulder
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
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Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
M05.819
M05.821
M05.822
M05.829
M05.831
M05.832
M05.839
M05.841
M05.842
M05.849
M05.851
M05.852
M05.859
M05.861
M05.862
M05.869
M05.871
M05.872
M05.879
M05.89
M05.9
M06.00
M06.011
M06.012
M06.019
M06.021
M06.022
M06.029
M06.031
M06.032
M06.039
M06.041
M06.042
M06.049
M06.051
M06.052
M06.059
M06.061
M06.062
M06.069
M06.071
M06.072
M06.079
M06.08
M06.09
M06.1
M06.20
M06.211
M06.212
M06.219
M06.221
Other rheumatoid arthritis with rheumatoid factor of unspecified
shoulder
Other rheumatoid arthritis with rheumatoid factor of right elbow
Other rheumatoid arthritis with rheumatoid factor of left elbow
Other rheumatoid arthritis with rheumatoid factor of unspecified elbow
Other rheumatoid arthritis with rheumatoid factor of right wrist
Other rheumatoid arthritis with rheumatoid factor of left wrist
Other rheumatoid arthritis with rheumatoid factor of unspecified wrist
Other rheumatoid arthritis with rheumatoid factor of right hand
Other rheumatoid arthritis with rheumatoid factor of left hand
Other rheumatoid arthritis with rheumatoid factor of unspecified hand
Other rheumatoid arthritis with rheumatoid factor of right hip
Other rheumatoid arthritis with rheumatoid factor of left hip
Other rheumatoid arthritis with rheumatoid factor of unspecified hip
Other rheumatoid arthritis with rheumatoid factor of right knee
Other rheumatoid arthritis with rheumatoid factor of left knee
Other rheumatoid arthritis with rheumatoid factor of unspecified knee
Other rheumatoid arthritis with rheumatoid factor of right ankle and
foot
Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
Other rheumatoid arthritis with rheumatoid factor of unspecified ankle
and foot
Other rheumatoid arthritis with rheumatoid factor of multiple sites
Rheumatoid arthritis with rheumatoid factor, unspecified
Rheumatoid arthritis without rheumatoid factor, unspecified site
Rheumatoid arthritis without rheumatoid factor, right shoulder
Rheumatoid arthritis without rheumatoid factor, left shoulder
Rheumatoid arthritis without rheumatoid factor, unspecified shoulder
Rheumatoid arthritis without rheumatoid factor, right elbow
Rheumatoid arthritis without rheumatoid factor, left elbow
Rheumatoid arthritis without rheumatoid factor, unspecified elbow
Rheumatoid arthritis without rheumatoid factor, right wrist
Rheumatoid arthritis without rheumatoid factor, left wrist
Rheumatoid arthritis without rheumatoid factor, unspecified wrist
Rheumatoid arthritis without rheumatoid factor, right hand
Rheumatoid arthritis without rheumatoid factor, left hand
Rheumatoid arthritis without rheumatoid factor, unspecified hand
Rheumatoid arthritis without rheumatoid factor, right hip
Rheumatoid arthritis without rheumatoid factor, left hip
Rheumatoid arthritis without rheumatoid factor, unspecified hip
Rheumatoid arthritis without rheumatoid factor, right knee
Rheumatoid arthritis without rheumatoid factor, left knee
Rheumatoid arthritis without rheumatoid factor, unspecified knee
Rheumatoid arthritis without rheumatoid factor, right ankle and foot
Rheumatoid arthritis without rheumatoid factor, left ankle and foot
Rheumatoid arthritis without rheumatoid factor, unspecified ankle and
foot
Rheumatoid arthritis without rheumatoid factor, vertebrae
Rheumatoid arthritis without rheumatoid factor, multiple sites
Adult-onset Still's disease
Rheumatoid bursitis, unspecified site
Rheumatoid bursitis, right shoulder
Rheumatoid bursitis, left shoulder
Rheumatoid bursitis, unspecified shoulder
Rheumatoid bursitis, right elbow
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
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Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
M06.222
M06.229
M06.231
M06.232
M06.239
M06.241
M06.242
M06.249
M06.251
M06.252
M06.259
M06.261
M06.262
M06.269
M06.271
M06.272
M06.279
M06.28
M06.29
M06.30
M06.311
M06.312
M06.319
M06.321
M06.322
M06.329
M06.331
M06.332
M06.339
M06.341
M06.342
M06.349
M06.351
M06.352
M06.359
M06.361
M06.362
M06.369
M06.371
M06.372
M06.379
M06.38
M06.39
M06.80
M06.811
M06.812
M06.819
M06.821
M06.822
M06.829
M06.831
M06.832
M06.839
M06.841
M06.842
Rheumatoid bursitis, left elbow
Rheumatoid bursitis, unspecified elbow
Rheumatoid bursitis, right wrist
Rheumatoid bursitis, left wrist
Rheumatoid bursitis, unspecified wrist
Rheumatoid bursitis, right hand
Rheumatoid bursitis, left hand
Rheumatoid bursitis, unspecified hand
Rheumatoid bursitis, right hip
Rheumatoid bursitis, left hip
Rheumatoid bursitis, unspecified hip
Rheumatoid bursitis, right knee
Rheumatoid bursitis, left knee
Rheumatoid bursitis, unspecified knee
Rheumatoid bursitis, right ankle and foot
Rheumatoid bursitis, left ankle and foot
Rheumatoid bursitis, unspecified ankle and foot
Rheumatoid bursitis, vertebrae
Rheumatoid bursitis, multiple sites
Rheumatoid nodule, unspecified site
Rheumatoid nodule, right shoulder
Rheumatoid nodule, left shoulder
Rheumatoid nodule, unspecified shoulder
Rheumatoid nodule, right elbow
Rheumatoid nodule, left elbow
Rheumatoid nodule, unspecified elbow
Rheumatoid nodule, right wrist
Rheumatoid nodule, left wrist
Rheumatoid nodule, unspecified wrist
Rheumatoid nodule, right hand
Rheumatoid nodule, left hand
Rheumatoid nodule, unspecified hand
Rheumatoid nodule, right hip
Rheumatoid nodule, left hip
Rheumatoid nodule, unspecified hip
Rheumatoid nodule, right knee
Rheumatoid nodule, left knee
Rheumatoid nodule, unspecified knee
Rheumatoid nodule, right ankle and foot
Rheumatoid nodule, left ankle and foot
Rheumatoid nodule, unspecified ankle and foot
Rheumatoid nodule, vertebrae
Rheumatoid nodule, multiple sites
Other specified rheumatoid arthritis, unspecified site
Other specified rheumatoid arthritis, right shoulder
Other specified rheumatoid arthritis, left shoulder
Other specified rheumatoid arthritis, unspecified shoulder
Other specified rheumatoid arthritis, right elbow
Other specified rheumatoid arthritis, left elbow
Other specified rheumatoid arthritis, unspecified elbow
Other specified rheumatoid arthritis, right wrist
Other specified rheumatoid arthritis, left wrist
Other specified rheumatoid arthritis, unspecified wrist
Other specified rheumatoid arthritis, right hand
Other specified rheumatoid arthritis, left hand
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
9
Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.
M06.849
M06.851
M06.852
M06.859
M06.861
M06.862
M06.869
M06.871
M06.872
M06.879
M06.88
M06.89
M06.9
Other specified rheumatoid arthritis, unspecified hand
Other specified rheumatoid arthritis, right hip
Other specified rheumatoid arthritis, left hip
Other specified rheumatoid arthritis, unspecified hip
Other specified rheumatoid arthritis, right knee
Other specified rheumatoid arthritis, left knee
Other specified rheumatoid arthritis, unspecified knee
Other specified rheumatoid arthritis, right ankle and foot
Other specified rheumatoid arthritis, left ankle and foot
Other specified rheumatoid arthritis, unspecified ankle and foot
Other specified rheumatoid arthritis, vertebrae
Other specified rheumatoid arthritis, multiple sites
Rheumatoid arthritis, unspecified
REFERENCES
1. Simponi Aria [package insert]. Horsham, PA: Janssen Biotech, Inc; February 2014.
rd
2. Weinblatt ME, Bingham CO 3 , Mendelsohn AM, et al. Intravenous golimumab is effective in patients
with active rheumatoid arthritis despite methotrexate therapy with responses as early as week 2:
results of the phase 3, randomised, multicentre, double-blind, placebo-controlled GO-FURTHER trial.
Ann Rheum Dis. 2013 Mar;72(3):381-9. doi: 10.1136/annrheumdis-2012-201411. Epub 2012 Jun 1.
™
th
3. MCG Ambulatory Care 18 Edition. Golimumab. Available at:
http://careweb.careguidelines.com/ed17/index.html Accessed December 3, 2014.
4. Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology
Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the
Treatment of Rheumatoid Arthritis. Arthritis Care & Research. 2012 May;64(5):625–639. DOI
10.1002/acr.2164.
POLICY HISTORY/REVISION INFORMATION
Date
3/1/2015
Action/Description
New policy 2015D0051A. Approved by National Pharmacy & Therapeutics
Committee on 11/19/2014.
Simponi Aria (golimumab): Drug Policy (Effective 03/01/2015)
10
Proprietary Information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc.