Get the free Golimumab (Simponi®) Injectable Medication Precertification Request
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This document serves as a request for precertification of the medication Golimumab, commonly known as Simponi, to be completed by healthcare providers and submitted to Aetna for review.
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How to fill out golimumab simponi injectable medication
How to fill out Golimumab (Simponi®) Injectable Medication Precertification Request
01
Obtain the Golimumab (Simponi®) Injectable Medication Precertification Request form from your healthcare provider or insurance company.
02
Fill in the patient's personal information including name, date of birth, and insurance details.
03
Provide information about the medical diagnosis and the reason for the request.
04
Include relevant medical history and previous treatments attempted, along with their outcomes.
05
Attach any necessary medical records or supporting documents that justify the need for Golimumab.
06
Indicate the prescribed dosage and frequency of the Golimumab injections as recommended by the healthcare provider.
07
Sign and date the form to confirm the information is accurate and complete.
08
Submit the completed precertification request form to the insurance company using the method specified (fax, online portal, or mail).
09
Follow up with the insurance company to ensure the request is processed and to address any additional information they may require.
Who needs Golimumab (Simponi®) Injectable Medication Precertification Request?
01
Patients diagnosed with conditions such as rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, or ankylosing spondylitis who are being considered for Golimumab treatment.
02
Patients who have not responded adequately to other treatment options and require medication management.
03
Patients enrolled in specific treatment programs that necessitate precertification before starting therapy.
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People Also Ask about
What conditions does SIMPONI ARIA treat?
SIMPONI ARIA® is a prescription medication used to treat moderate to severe rheumatoid arthritis (RA) in adults, used in combination with methotrexate; active psoriatic arthritis (PsA) in people 2 years of age and older; active ankylosing spondylitis (AS) in adults and active polyarticular juvenile idiopathic arthritis
Is Simponi a high risk medication?
Patients treated with SIMPONI® () are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids.
What conditions is SIMPONI ARIA approved for?
SIMPONI ARIA is indicated for the treatment of active psoriatic arthritis in patients 2 years of age and older. SIMPONI ARIA is indicated for the treatment of adult patients with active ankylosing spondylitis.
Is FDA approved for rheumatoid arthritis?
This drug is FDA-approved for treating active moderate to severe rheumatoid arthritis in sequence with first-line therapy methotrexate, active psoriatic arthritis, active ankylosing spondylitis, and patients with moderate to severe ulcerative colitis unable to achieve an adequate response to previous therapy, or
Is SIMPONI ARIA approved for ankylosing spondylitis?
On October 20, 2017, the US Food and Drug Administration (FDA) approved (Simponi Aria; Janssen) for the treatment of adults with active psoriatic arthritis or with active ankylosing spondylitis.
Does Medicare pay for SIMPONI ARIA infusions?
Do Medicare prescription drug plans cover Simponi Aria? No. In general, Medicare prescription drug plans (Part D) do not cover this drug. Be sure to contact your specific plan to verify coverage information.
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What is Golimumab (Simponi®) Injectable Medication Precertification Request?
Golimumab (Simponi®) Injectable Medication Precertification Request is a formal process to obtain prior approval from a health insurance provider before a patient can receive treatment with Golimumab, which is used to manage autoimmune diseases.
Who is required to file Golimumab (Simponi®) Injectable Medication Precertification Request?
The healthcare provider prescribing the medication is required to file the Golimumab (Simponi®) Injectable Medication Precertification Request on behalf of the patient.
How to fill out Golimumab (Simponi®) Injectable Medication Precertification Request?
To fill out the precertification request, the provider should complete all necessary patient and provider information, including diagnosis codes, treatment history, and specific details about the prescribed Golimumab treatment.
What is the purpose of Golimumab (Simponi®) Injectable Medication Precertification Request?
The purpose of the precertification request is to ensure that the treatment is medically necessary and to facilitate coverage and reimbursement from the patient’s insurance provider.
What information must be reported on Golimumab (Simponi®) Injectable Medication Precertification Request?
The request must include patient demographics, diagnosis, previous treatments, reasons for the current treatment plan, and any relevant laboratory or medical documentation supporting the need for Golimumab therapy.
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