Does J1602 require prior authorization?

Yes, J1602 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1602?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J1602`, Injection, golimumab, 1 mg, for intravenous use

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documented negative tuberculosis (TB) test (PPD, IGRA, or chest x-ray) within 6 months of initiating therapy for persons naive to biologic drugs or targeted synthetic drugs associated with increased TB risk; if TB test positive, documentation of further testing to exclude active TB and documentation that latent TB treatment was initiated prior to golimumab.
For RA initial approval when required: documentation of RF and/or anti-CCP testing results and CRP and/or ESR (as required by the RA criteria), OR documentation of positive RF or anti-CCP.
Documentation of prior therapies and responses: e.g., for RA: documentation of prior biologic or targeted synthetic drug use OR documentation of inadequate response to at least a 3-month trial of methotrexate titrated to at least 15 mg/week (or documentation of intolerance/contraindication to methotrexate/leflunomide with stated clinical reason per Appendix A).
For PsA: documentation of age (2+ where applicable), prior biologic or targeted synthetic drug use if applicable, OR documentation of inadequate response to methotrexate, leflunomide, or another conventional synthetic DMARD at adequate dose/duration OR documentation of intolerance/contraindication; documentation if enthesitis or predominantly axial disease or severe disease is the rationale.
For AS / nr-axSpA: documentation of inadequate response to at least two NSAIDs (or documentation of intolerance/contraindication to two or more NSAIDs).
For articular JIA: documentation of age (2+), prior biologic or targeted synthetic drug use if applicable, OR documentation of inadequate response to methotrexate or another conventional synthetic drug at adequate dose/duration OR documentation of inadequate response to scheduled NSAID and/or intra-articular glucocorticoids plus presence of listed risk factors for poor outcome; documentation of risk factors for disease severity as per Appendix B when applicable.

Key Coverage Criteria

Intravenously administered golimumab (Simponi Aria) is medically necessary for members with a documented negative tuberculosis (TB) test (PPD, IGRA, or chest x-ray) within 6 months for persons who are naive to biologic drugs or targeted synthetic drugs associated with an increased risk of TB, for the following:
Rheumatoid arthritis (RA): For adult members who have previously received a biologic or targeted synthetic drug indicated for moderately to severely active rheumatoid arthritis. The requested medication must be prescribed in combination with methotrexate unless the member has a clinical reason not to use methotrexate or leflunomide; OR for adult members for treatment of moderately to severely active RA when all of the following are met: (a) member has either a positive test for rheumatoid factor [...]
Psoriatic arthritis (PsA) (IV Simponi Aria): For members 2 years of age or older who have previously received a biologic or targeted synthetic drug indicated for active psoriatic arthritis; OR for members 2 years of age or older for treatment of active psoriatic arthritis when either: (a) member has mild to moderate disease and has had an inadequate response to methotrexate, leflunomide, or another conventional synthetic drug administered at an adequate dose and duration OR has an intolerance or [...]
Ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) (IV Simponi Aria): For adult members who have previously received a biologic or targeted synthetic drug indicated for active AS or nr-axSpA; OR for adult members for treatment of active AS or nr-axSpA when either: (a) member has experienced an inadequate response to at least two non-steroidal anti-inflammatory drugs (NSAIDs); OR (b) member has an intolerance or contraindication to two or more NSAIDs.
Articular juvenile idiopathic arthritis (JIA) (IV Simponi Aria): For members 2 years of age or older who have previously received a biologic or targeted synthetic drug indicated for active articular juvenile idiopathic arthritis; OR for members 2 years of age or older for treatment of active articular JIA when any of the following is met: (a) member has had an inadequate response to methotrexate or another conventional synthetic drug administered at an adequate dose and duration; OR (b) member h [...]
Immune checkpoint inhibitor-related toxicity (IV Simponi Aria): For treatment of immune checkpoint inhibitor-related toxicity when the member has severe immunotherapy-related inflammatory arthritis and has experienced an inadequate response to corticosteroids OR has an intolerance or contraindication to corticosteroids.

20 Active Policies

ARKBLUE-GOLIMUMAB-E-G-SIMPONI-ARIA-F009B37460, Golimumab (e.g., Simponi Aria)

FLORIDA_BLUE-FLBLUE-SIMPONI-ARIA-GOLIMUMAB-INJECTION-FOR-INTRAVENOUS-USE-C1CB20166F, Simponi Aria (Golimumab Injection for Intravenous Use)

BCIDAHO-05-01-670-67638B3210, Simponi Aria (Golimumab) for Intravenous Use. Medical Policy MP 5.01.670 Simponi Aria (golimumab) for Intravenous Use DISCLAIMER/INSTRUCTIONS FOR USE This medical policy provides general

BCBSLA-00223-F6CA7A9940, 00223 golimumab (Simponi Aria, Simponi)

BCBSND-GOLIMUMAB-SIMPONI-ARIA-337210DB2D, Golimumab Simponi Aria

BCBSNJ-DRUGS-068-B203904DCB, Golimumab (Simponi Aria)

MODA-GOLIMUMAB-5378D62607, Simponi ARIA (golimumab)

IBX-MEDICARE-ADVANTAGE-MA08-070G-A9310F58FD, Golimumab (Simponi Aria) Intravenous (IV) Injection

IBX-COMMERCIAL-08-01-15H-59E3384FBD, Golimumab (Simponi Aria) Intravenous (IV) Injection

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.112, Golimumab

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-simponi-aria-golimumab-injection-intravenous-infusion, Simponi Aria (Golimumab) Injection for Intravenous Infusion

SUREST-POL-SUREST-simponi-aria-golimumab-injection-intravenous-infusion, Simponi Aria (Golimumab) Injection for Intravenous Infusion

AETNA-CPB-0790, Golimumab (Simponi and Simponi Aria)

AMERIHEALTH-COMMERCIAL-08-01-15H-75E18A9453, Golimumab (Simponi Aria) Intravenous (IV) Injection

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-070G-3AF4266CA1, Golimumab (Simponi Aria) Intravenous (IV) Injection

BCBSTN-7ebe248fc4, Golimumab (Simponi ARIA)

EVICORE-MEDICAL_DRUG-4200CCDBF930, Simponi Aria (golimumab)

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J1602, Injection, golimumab, 1 mg, for intravenous use

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documented negative tuberculosis (TB) test (PPD, IGRA, or chest x-ray) within 6 months of initiating therapy for persons naive to biologic drugs or targeted synthetic drugs associated with increased TB risk; if TB test positive, documentation of further testing to exclude active TB and documentation that latent TB treatment was initiated prior to golimumab.
For RA initial approval when required: documentation of RF and/or anti-CCP testing results and CRP and/or ESR (as required by the RA criteria), OR documentation of positive RF or anti-CCP.
Documentation of prior therapies and responses: e.g., for RA: documentation of prior biologic or targeted synthetic drug use OR documentation of inadequate response to at least a 3-month trial of methotrexate titrated to at least 15 mg/week (or documentation of intolerance/contraindication to methotrexate/leflunomide with stated clinical reason per Appendix A).
For PsA: documentation of age (2+ where applicable), prior biologic or targeted synthetic drug use if applicable, OR documentation of inadequate response to methotrexate, leflunomide, or another conventional synthetic DMARD at adequate dose/duration OR documentation of intolerance/contraindication; documentation if enthesitis or predominantly axial disease or severe disease is the rationale.
For AS / nr-axSpA: documentation of inadequate response to at least two NSAIDs (or documentation of intolerance/contraindication to two or more NSAIDs).
For articular JIA: documentation of age (2+), prior biologic or targeted synthetic drug use if applicable, OR documentation of inadequate response to methotrexate or another conventional synthetic drug at adequate dose/duration OR documentation of inadequate response to scheduled NSAID and/or intra-articular glucocorticoids plus presence of listed risk factors for poor outcome; documentation of risk factors for disease severity as per Appendix B when applicable.

Key Coverage Criteria

Intravenously administered golimumab (Simponi Aria) is medically necessary for members with a documented negative tuberculosis (TB) test (PPD, IGRA, or chest x-ray) within 6 months for persons who are naive to biologic drugs or targeted synthetic drugs associated with an increased risk of TB, for the following:
Rheumatoid arthritis (RA): For adult members who have previously received a biologic or targeted synthetic drug indicated for moderately to severely active rheumatoid arthritis. The requested medication must be prescribed in combination with methotrexate unless the member has a clinical reason not to use methotrexate or leflunomide; OR for adult members for treatment of moderately to severely active RA when all of the following are met: (a) member has either a positive test for rheumatoid factor [...]
Psoriatic arthritis (PsA) (IV Simponi Aria): For members 2 years of age or older who have previously received a biologic or targeted synthetic drug indicated for active psoriatic arthritis; OR for members 2 years of age or older for treatment of active psoriatic arthritis when either: (a) member has mild to moderate disease and has had an inadequate response to methotrexate, leflunomide, or another conventional synthetic drug administered at an adequate dose and duration OR has an intolerance or [...]
Ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) (IV Simponi Aria): For adult members who have previously received a biologic or targeted synthetic drug indicated for active AS or nr-axSpA; OR for adult members for treatment of active AS or nr-axSpA when either: (a) member has experienced an inadequate response to at least two non-steroidal anti-inflammatory drugs (NSAIDs); OR (b) member has an intolerance or contraindication to two or more NSAIDs.
Articular juvenile idiopathic arthritis (JIA) (IV Simponi Aria): For members 2 years of age or older who have previously received a biologic or targeted synthetic drug indicated for active articular juvenile idiopathic arthritis; OR for members 2 years of age or older for treatment of active articular JIA when any of the following is met: (a) member has had an inadequate response to methotrexate or another conventional synthetic drug administered at an adequate dose and duration; OR (b) member h [...]
Immune checkpoint inhibitor-related toxicity (IV Simponi Aria): For treatment of immune checkpoint inhibitor-related toxicity when the member has severe immunotherapy-related inflammatory arthritis and has experienced an inadequate response to corticosteroids OR has an intolerance or contraindication to corticosteroids.

20 Active Policies

ARKBLUE-GOLIMUMAB-E-G-SIMPONI-ARIA-F009B37460, Golimumab (e.g., Simponi Aria)

FLORIDA_BLUE-FLBLUE-SIMPONI-ARIA-GOLIMUMAB-INJECTION-FOR-INTRAVENOUS-USE-C1CB20166F, Simponi Aria (Golimumab Injection for Intravenous Use)

BCBSLA-00223-F6CA7A9940, 00223 golimumab (Simponi Aria, Simponi)

BCBSND-GOLIMUMAB-SIMPONI-ARIA-337210DB2D, Golimumab Simponi Aria

BCBSNJ-DRUGS-068-B203904DCB, Golimumab (Simponi Aria)

MODA-GOLIMUMAB-5378D62607, Simponi ARIA (golimumab)

IBX-MEDICARE-ADVANTAGE-MA08-070G-A9310F58FD, Golimumab (Simponi Aria) Intravenous (IV) Injection

IBX-COMMERCIAL-08-01-15H-59E3384FBD, Golimumab (Simponi Aria) Intravenous (IV) Injection

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.112, Golimumab

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-simponi-aria-golimumab-injection-intravenous-infusion, Simponi Aria (Golimumab) Injection for Intravenous Infusion

SUREST-POL-SUREST-simponi-aria-golimumab-injection-intravenous-infusion, Simponi Aria (Golimumab) Injection for Intravenous Infusion

AETNA-CPB-0790, Golimumab (Simponi and Simponi Aria)

AMERIHEALTH-COMMERCIAL-08-01-15H-75E18A9453, Golimumab (Simponi Aria) Intravenous (IV) Injection

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-070G-3AF4266CA1, Golimumab (Simponi Aria) Intravenous (IV) Injection

BCBSTN-7ebe248fc4, Golimumab (Simponi ARIA)

EVICORE-MEDICAL_DRUG-4200CCDBF930, Simponi Aria (golimumab)

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J1602 Sign up free

`J1602`, Injection, golimumab, 1 mg, for intravenous use

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1602`, Injection, golimumab, 1 mg, for intravenous use

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1602, Injection, golimumab, 1 mg, for intravenous use

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J1602, Injection, golimumab, 1 mg, for intravenous use

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J1602`, Injection, golimumab, 1 mg, for intravenous use

`J1602`, Injection, golimumab, 1 mg, for intravenous use