Limited coverage drugs – golimumab

Last updated on August 27, 2024
Generic name Strength Form
golimumab 50 MG/0.5 ML pen injector 
golimumab 50 MG/4 ML I.V. vial
golimumab 50 MG/0.5 ML syringe

 

Special Authority Criteria

Approval period

1. Treatment of Rheumatoid Arthritis according to established criteria* when prescribed by a rheumatologist 1 year
2. Treatment of Psoriatic Arthritis according to established criteria* when prescribed by a rheumatologist 1 year
3. Treatment of Ankylosing Spondylitis according to established criteria* when prescribed by a rheumatologist 1 year

Practitioner exemptions

  • None

Special notes

  • For coverage, the maximum allowable supply of golimumab is one month of medication per fill.

Special Authority request form(s)

Log in to eForms or​ click on the appropriate Special Authority Form below for full criteria:

Rheumatoid Arthritis

Psoriatic Arthritis

Ankylosing Spondylitis: