Simponi
| Covered Uses: | All FDA-approved indications not otherwise excluded from Part D |
| Exclusion Criteria: | Coverage is not provided for use in combination with other biologics e.g., Humira, Kineret, Remicade, etc. |
| Required Medical Information: | Coverage is provided in situations where the patient has been evaluated and screened for the presence of latent TB infection, where warranted, prior to initiating treatment with Simponi. Coverage is provided in situations where the patient experienced intolerance/failure to Humira AND Enbrel. For rheumatoid arthritis, Simponi must be used in combination with methotrexate, per labeling. |
| Age Restrictions: | |
| Prescriber Restrictions: | |
| Coverage Duration: | 12 months |
| Other Criteria: | Renewal coverage is provided in situations where treatment has provided clinical benefit. |
Last Modified on 12/19/2012