Limited coverage drugs – golimumab

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

• 5345 - Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Rheumatoid Arthritis - Initial/Switch (PDF)
• 5354 - Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Rheumatoid Arthritis - Renewal (PDF)
• 5383 - Health Assessment Questionnaire (HAQ) (PDF)

Psoriatic Arthritis

• 5360 - Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis – Initial/Switch (PDF)
• 5361 - Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis - Renewal (PDF)
• 5364 - Bath Ankylosing Spondylitis - Disease Activity Index (BASDAI) (PDF)
• 5383 - Health Assessment Questionnaire (HAQ) (PDF)

Ankylosing Spondylitis:

• 5365 - Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis – Initial/Switch (PDF)
• 5366 - Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis - Renewal (PDF)
• 5364 - Bath Ankylosing Spondylitis - Disease Activity Index (BASDAI) (PDF)