Anthem Blue Cross (HMO, PPO, EPO)
Simponi (golimumab)
Drugs for Pain and Fever : Arthritis and Pain Drugs
  • Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

    Psoriatic Arthritis (PsA):
    Age Requirement: >= 18
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

  • Prior Authorization: Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 1 year(s)
    Reauthorization Required: Yes

    Psoriatic Arthritis (PsA):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Reauthorization Required: Yes

  • PA Applies
  • Available only through Specialty Pharmacy;
    For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on drug coverage click HERE;
  • Quantity Limit: 1 syringe per 28 day(s).
  • Step Therapy: ST Single Generic

<< Return | Back to top