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Simponi Aria (golimumab)


Billing

Code: J1602

Description: Golimumab for iv use 1mg

Unit: 1 mg

Payment: $13.287

Pay quarter: Q3 2023


Medicare history

Dosage and Frequency

Rheumatoid Arthritis (RA)
Psoriatic Arthritis (PsA)
Ankylosing Spondylitis (AS)

Induction:
• 2mg/kg IV at weeks 0 and 4

Maintenance:
• 2mg/kg IV every 8 weeks

Calculate drug reimbursement


Total Reimbursement:

$2,112.63

(ASP: $1,993.05, Margin: $119.58)


Code:

J1602

# Units to bill:

150

Prior Authorization

Prior auth criteria for Simponi Aria may include but is not limited to:


1. Diagnosis of active, moderate to severe ulcerative colitis including pancolitis, left-sided colitis, or extensive colitis.

2. Failure of conventional therapy, defined as inadequate response to or intolerance of one or more conventional therapies.

3. Absence of any contraindications for use of Simponi Aria.

4. The prescriber must provide documentation of patient’s height, weight, and laboratory values.

5. The prescriber must provide documentation of the patient’s medical history, current medications, and previous treatments.

6. The prescriber must provide documentation of the patient’s response to conventional therapies.

7. The prescriber must provide documentation of the patient’s baseline laboratory values.

8. The prescriber must provide documentation of the patient’s current disease activity.

9. The prescriber must provide documentation of the patient’s response to previous treatments with biologic therapies.

10. The prescriber must provide documentation of the patient’s willingness and ability to comply with the necessary laboratory monitoring.


Insurance prior auth guidelines:

Aetna

United Healthcare

Cigna

Anthem


Billable NDCs

57894-0350-01

SIMPONI ARIA (JANSSEN BIOTECH, INC.)

50 MG



Resources

Drug Enrollment Form

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