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Call Cancer Center scheduler (831) 622-2744 Treatment Date:______Fax order to (831) 622-2734

Golimumab (Simponi aria) Ini�al dose: 2 mg/kg IV at 0 and 4 weeks. Infuse over 30 minutes. Dose: ______Golimumab (Simponi aria) Maintenance dose: 2 mg/kg IV every 8 weeks. Infuse over 30 minutes. Dose: ______Per P&T policy, round dose to the nearest 50 mg vial size.

Height ______Weight ______

**PRIOR AUTHORIZATION NUMBER: ______Expiration of Authorization ______Primary diagnosis AND Supportive Documentation are REQUIRED

PRIMARY DIAGNOSIS – Check one Must send documenta�on of the following criteria with order: √ ICD-10 Descrip�on Simponi aria is medically necessary for the treatment of Psoria�c arthri�s when ALL of the following criteria are met: 1. Diagnosis of ac�ve psoria�c arthri�s 2. Simponi Aria is ini�ated and �trated according to U.S. Food and Drug Administra�on (FDA) labeled dosing for psoria�c arthri�s up to a maximum of 2 mg/kg at weeks 0 and 4 upon ini�a�on of therapy, then 2 mg/kg every 8 weeks (or equivalent dose and interval schedule); and 3. Pa�ent is not receiving Simponi Aria in combina�on with any of the following: a. Biologic disease-modifying an�rheuma�c drug (DMARD) [e.g., Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Orencia (abatacept)] b. Janus kinase inhibitor [e.g., Xeljanz (tofaci�nib)]5 c. Phosphodiesterase 4 (PDE4) inhibitor [e.g., Otezla (apremilast)]

Psoria�c L40.50 For con�nua�on therapy, all of the following: Arthri�s 1. Pa�ent has previously received treatment with golimumab; and 2. Documenta�on of posi�ve clinical response to golimumab therapy; and 3. Pa�ent is not receiving golimumab in combina�on with any of the following: a. Disease modifying therapy (e.g., interferon beta prepara�ons, dimethyl fumarate, gla�ramer acetate, natalizumab, fingolimod, cladribine, siponimod, or teriflunomide) b. B cell targeted therapy (e.g., rituximab, belimumab, ofatumumab) c. Lymphocyte trafficking blockers (e.g., alemtuzumab, mitoxantrone); and 4. Con�nued dosing: One 600 mg intravenous dose every 6 months; and 5. Authoriza�on is for no more than 12 months.

GOLIMUMAB (SIMPONI ARIA) ORDERS 901571 / 7710 (10/20) Page 2 of 2

PRIMARY DIAGNOSIS – Check one Must send documenta�on of the following criteria with order: ICD-10 Descrip�on Ordering physician to fill in narra�ve diagnosis if not among the selec�ons, Other and provide documenta�on to support medical necessity. Orders with diagnoses that don’t meet medical necessity will be returned to the physician as not mee�ng medical necessity for treatment.

______Time Date Physician signature Print physician full name

GOLIMUMAB (SIMPONI ARIA) ORDERS

901571 / 7710 (10/20)