Aetna Golimumab (Simponi/Simponi Aria) Coverage Policy Update — CPB 0790 (Effective March 2026)

Aetna, a CVS Health company, has modified Clinical Policy Bulletin CPB 0790, which governs coverage of golimumab (Simponi and Simponi Aria) under commercial medical plans, effective March 13, 2026. This update carries significant implications for rheumatology, dermatology, and oncology practices billing for both the subcutaneous (Simponi) and intravenous (Simponi Aria) formulations. If your team is managing prior authorization requests or continuations of care for any golimumab indication, you need to review the updated medical necessity criteria now.

Field	Detail
Payer	Aetna (CVS Health)
Policy	Golimumab (Simponi) — CPB 0790
Policy Code	CPB 0790
Change Type	Modified
Effective Date	2026-03-13
Impact Level	High
Specialties Affected	Rheumatology, Dermatology, Oncology, Hematology, Infusion/Specialty Pharmacy
Key Action	Audit active golimumab prior authorization requests and renewals against the updated biomarker testing and step therapy criteria before submitting claims.

---

Aetna CPB 0790 — What Changed in the 2026 Golimumab Policy

The March 2026 modification to CPB 0790 updates the medical necessity framework for both Simponi (subcutaneous) and Simponi Aria (intravenous golimumab). While the full policy document details changes across multiple indications, the criteria governing rheumatoid arthritis (RA) — golimumab's most common use case — reflect a more structured, biomarker-driven approval pathway. Billing and authorization teams should treat this as a substantive revision, not a routine refresh.

One critical administrative note that has not changed but warrants emphasis: precertification of Simponi Aria (intravenous golimumab) is required for all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277 to initiate. Failure to precertify before infusion will result in a denial—period.

Additionally, Aetna's Site of Care Utilization Management Policy applies to Simponi Aria infusions under commercial plans. Before scheduling an infusion at a hospital outpatient department, confirm that the site of service meets Aetna's requirements. Infusions administered at a non-preferred site may be denied even when the drug itself is approved.

---

Aetna Golimumab Prescriber Specialty Requirements

Aetna limits which prescribers can initiate golimumab therapy. This isn't just a coverage nuance — it's a hard prior auth requirement. If the prescriber doesn't meet the specialty criteria, the authorization will be denied regardless of how well the clinical documentation supports the diagnosis.

• Rheumatoid arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and articular juvenile idiopathic arthritis: Must be prescribed by or in consultation with a rheumatologist
• Psoriatic arthritis: Must be prescribed by or in consultation with a rheumatologist or dermatologist
• Immune checkpoint inhibitor-related toxicity: Must be prescribed by or in consultation with an oncologist, hematologist, or rheumatologist

---

Aetna Golimumab Medical Necessity Criteria — Rheumatoid Arthritis (2026)

The RA criteria under CPB 0790 offer 2 pathways to initial approval for Simponi Aria.

Pathway 1 — Prior biologic or targeted synthetic DMARD experience: Adult members who have previously received a biologic or targeted synthetic drug (such as Rinvoq or Xeljanz) for moderately to severely active RA qualify, provided golimumab is prescribed in combination with methotrexate. An exception applies if the member has a documented clinical reason not to use methotrexate or leflunomide, as defined in the policy's Appendix A.

Pathway 2 — Conventional DMARD step therapy with biomarker evidence: For members who haven't yet tried a biologic, Aetna requires ALL of the following:

#	Covered Indication Copy
1	Biomarker testing: The member must have been tested for rheumatoid factor (RF) and/or anti-CCP — with a positive result on at least one — OR must have been tested for RF, anti-CCP, and CRP/ESR (regardless of result).
2	Step therapy failure: The member must have failed to achieve low disease activity after at least 3 months of methotrexate monotherapy at a maximum titrated dose of at least 15 mg/week. Exceptions exist for documented intolerance, contraindications to hydroxychloroquine and sulfasalazine, or moderate-to-high disease activity.

The biomarker documentation requirement is a significant authorization friction point. Make sure RF (CPT 86430 or 86431), anti-CCP (CPT 86200), and CRP (CPT 86140 or 86141) or ESR (CPT 85651 or 85652) results are explicitly included in every prior auth submission for new-start RA patients.

---

Tuberculosis Screening Before Golimumab Authorization

Aetna's policy, consistent with standard TNF inhibitor requirements, expects documentation of TB screening before initiating golimumab. Ensure these codes are present in the patient's chart and documented in your authorization request:

• 86480 — TB test, cell-mediated immunity, gamma interferon
• 86481 — TB test, cell-mediated immunity, gamma interferon enumeration
• 86580 — Skin test, tuberculosis, intradermal (PPD)

Missing TB screening documentation is a common, easily avoidable denial trigger for biologic auth requests.

---

Affected Codes

Billing Codes for Golimumab Administration

The primary HCPCS code for Simponi Aria infusions is:

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

There is no specific HCPCS code for subcutaneously administered golimumab (Simponi). Claims for the SubQ formulation require a different billing approach — confirm with your payer contract and pharmacy benefit carve-out rules.

Infusion Administration Codes

Diagnostic and Biomarker Codes Referenced in CPB 0790

Key Prior Therapy HCPCS Codes (Step Therapy Documentation)

These codes represent drugs Aetna may require as prior therapy — document their use or documented failure/contraindication in every auth submission:

---

What Your Billing Team Should Do

Copy Action Items

---