Golimumab (Simponi) — CPB 0790 | AETNA Coverage Update

Aetna modified CPB 0790 for golimumab (Simponi and Simponi Aria), effective January 9, 2026. Here's what billing teams need to know.

Aetna, a CVS Health company, updated its golimumab coverage policy under CPB 0790 on January 9, 2026. This update affects commercial plan billing for both subcutaneous golimumab (Simponi) and intravenous golimumab (Simponi Aria), with the primary billing code for the IV formulation being HCPCS J1602. If your team bills infusion services under CPT 96365–96368 or manages prior authorization for biologic therapy in rheumatology or dermatology, this update changes what you need to document before claims go out.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Golimumab (Simponi) — CPB 0790
Policy Code	CPB 0790
Change Type	Modified
Effective Date	January 9, 2026
Impact Level	High
Specialties Affected	Rheumatology, Dermatology, Oncology, Hematology
Key Action	Audit prior authorization documentation for biomarker testing and step therapy before submitting claims under J1602 and CPT 96365–96368

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Aetna Golimumab Coverage Criteria and Medical Necessity Requirements 2026

The core of the CPB 0790 Aetna coverage policy is a layered step-therapy requirement. The path to approval depends on the indication, the prescribing specialty, and whether the patient has documented biomarker results on file.

For intravenous golimumab (Simponi Aria, billed as J1602), Aetna requires precertification on all commercial plans. Call (866) 752-7021 or fax (888) 267-3277 to initiate prior authorization. Missing this step is the fastest route to a claim denial.

Prescriber Specialty Requirements

Aetna ties medical necessity approval to prescriber type. The prescriber must be, or must have consulted with, a qualifying specialist:

#	Covered Indication Copy
1	Rheumatoid arthritis (RA), ankylosing spondylitis, non-radiographic axial spondyloarthritis, articular juvenile idiopathic arthritis: Rheumatologist only
2	Psoriatic arthritis: Rheumatologist or dermatologist
3	Immune checkpoint inhibitor-related toxicity: Oncologist, hematologist, or rheumatologist

If the prescribing physician doesn't match these specialty requirements, the prior auth will fail. Flag this in your intake workflow before you ever submit the precertification.

Rheumatoid Arthritis — The Two Approval Pathways

Aetna's RA criteria offer two distinct routes to initial approval. Understanding both is critical for golimumab billing.

Pathway 1 — Prior biologic or targeted synthetic use: The member must have already used a biologic or targeted synthetic drug (e.g., Rinvoq/upadacitinib or Xeljanz/tofacitinib) for moderately to severely active RA. The golimumab request must be in combination with methotrexate, unless the member has a documented clinical reason to avoid both methotrexate and leflunomide.

Pathway 2 — Biomarker-documented, step-therapy naive: This path is more documentation-intensive. Aetna requires positive biomarker results — either rheumatoid factor (RF, billed as CPT 86430 or 86431) or anti-CCP (CPT 86200). If both RF and anti-CCP are negative, the member also needs documented C-reactive protein (CPT 86140 or 86141) and/or erythrocyte sedimentation rate (CPT 85651 or 85652) results on file.

After biomarker documentation, the member must show a failed 3-month trial of methotrexate at a maximum titrated dose of at least 15 mg per week. "Failed" means not reaching low disease activity. Aetna also requires evidence of one of the following alongside MTX failure:

Or, if the member couldn't tolerate the MTX trial itself, document the intolerance with specifics. Aetna won't accept vague language here. The claims examiner will look for exact language matching the policy criteria.

Tuberculosis Screening Is a Hard Requirement

Before Simponi Aria infusions begin, Aetna requires TB screening documentation. This means results from CPT 86480 or 86481 (IGRA testing) or CPT 86580 (TB skin test). No TB screening on file means no approval. Build this into your pre-authorization checklist now.

Site of Care Policy Applies to Simponi Aria

Aetna's Site of Care Utilization Management Policy applies to all Simponi Aria infusions on commercial plans. This affects where CPT 96365–96368 infusion services can be billed for reimbursement. Aetna may require infusions in a lower-cost setting before approving hospital outpatient or office-based infusion billing. If you're billing infusion administration codes for Simponi Aria from a hospital outpatient department, verify site-of-care requirements before January 9, 2026. Non-compliance here is a common source of claim denial.

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Aetna Golimumab Exclusions and Non-Covered Indications

The policy designates several uses as not medically necessary or experimental. The following are not covered under CPB 0790:

If you're billing for a use case that doesn't map cleanly to the covered indications, talk to your compliance officer before submitting. The financial exposure on a denied specialty drug claim is significant.

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Coverage Indications at a Glance

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Aetna Golimumab Billing Guidelines and Action Items 2026

The effective date is January 9, 2026. These steps apply now.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Golimumab Under CPB 0790

Primary Billing Code

Code	Type	Description Copy
J1602	HCPCS	Injection, golimumab, 1 mg, for intravenous use (Simponi Aria only)

Infusion Administration Codes

Biomarker and Screening CPT Codes

Imaging CPT Codes

Prior Therapy HCPCS Codes (Step Therapy Documentation)

These codes represent the conventional and biologic DMARDs Aetna references as required prior therapies. Document claims for these to support prior auth for golimumab.

Corticosteroid and Immunosuppressant Codes

Key ICD-10-CM Diagnosis Codes

Code	Description Copy
D86.0	Sarcoidosis of lung

The full ICD-10-CM code set under CPB 0790 includes 129 codes. Access the complete list at app.payerpolicy.org/p/aetna/0790.

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