Simponi Aria (golimumab)
Billing
Code: J1602
Description: Golimumab for iv use 1mg
Unit: 1 mg
Payment: $13.847
Pay quarter: Q1 2023
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
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:
$2,201.67(ASP: $2,077.05, Margin: $124.62)
Code:
J1602# Units to bill:
150Prior 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:
Billable NDCs
57894-0350-01
SIMPONI ARIA (JANSSEN BIOTECH, INC.)
50 MG
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