![]() ![]() The individual’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in DrugDex with 1 or 2a level of evidence, or NCCN compendium recommended use 1 or 2a for the treatment of AS and.The individual has an FDA labeled contraindication to ALL NSAIDs used in the treatment of AS or.The individual has an intolerance or hypersensitivity to two different NSAIDs used in the treatment of AS or.The individual has tried and had an inadequate response to two different NSAIDs used in the treatment of AS for at least a 4-week total trial or.The prescriber has provided information in support of using golimumab (Simponi Aria) for the individual’s age and.The individual is eighteen (18) years of age or older or.The prescriber states the individual has been treated with golimumab (Simponi Aria) (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed or.Information has been provided that indicates the individual has been treated with golimumab (Simponi Aria) (starting on samples is not approvable) within the past 90 days or.The individual has a diagnosis of active AS and.FEP members can also obtain the list through the Golimumab (Simponi Aria) may be considered medically necessary when an individual meets the criteria for ANY ONE of the following: Coverage is subject to the specific terms of the member's benefit plan.įederal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-80 (TTY: 1-80). ![]()
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