Simponi denied by insurance? Appeal and win.
A Simponi denial is rarely the final word. It is usually the opening move in a process, because most plans cover golimumab only after you document the specific prior therapies and clinical criteria buried in their policy. Denials most often turn on step therapy and missing prior-authorization documentation, and they flip when your appeal maps your record directly to the plan's own written criteria.
Reviewed by the Apellica Appeals Team · Updated June 2026
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Simponi (golimumab) is a subcutaneous, self-injected TNF inhibitor. It is FDA-approved for adults with moderately to severely active rheumatoid arthritis (given in combination with methotrexate), active psoriatic arthritis (alone or with methotrexate), and active ankylosing spondylitis. It is also approved for moderately to severely active ulcerative colitis in adults and in children weighing at least 33 pounds (15 kg). The intravenous infusion form, Simponi Aria, is a separate product with its own coverage rules and is typically billed under the medical benefit rather than the pharmacy benefit.
Why Simponi gets denied
- Step therapy not satisfied: most plans require a documented trial and inadequate response to conventional DMARDs (such as methotrexate for RA, with another DMARD in some policies) before a TNF inhibitor is approved.
- Preferred-biologic step therapy: many formularies require failure of a preferred TNF inhibitor (often adalimumab or its biosimilars) before covering Simponi, leaving it non-preferred or on a higher tier.
- Prior-authorization criteria not documented: missing diagnosis confirmation, disease-activity measures, or the specific drugs, doses, and trial durations the plan demands.
- Combination-therapy and safety gaps: for RA, lack of documented concurrent methotrexate, or missing baseline screening such as tuberculosis and hepatitis B testing that the plan requires before approval.
What a winning appeal includes
- Confirmed diagnosis with the correct ICD-10 code (for example M05/M06 for rheumatoid arthritis, L40.5/M07 for psoriatic arthritis, M45 for ankylosing spondylitis, or K51 for ulcerative colitis) plus objective disease-activity or endoscopic findings.
- A complete prior-therapy history listing each DMARD or biologic tried, the dose, the duration, and the reason it failed or was not tolerated, mapped to the plan's required trial periods.
- A letter of medical necessity that quotes the plan's own coverage criteria and shows point by point how the patient meets each one, including concurrent methotrexate for RA where required.
- Drug-specific safety documentation: negative or treated tuberculosis screening, hepatitis B status, and any other baseline labs the policy lists as conditions of approval.
How we approach the appeal
First identify which denial you received: a formulary or tier denial is fought with a formulary or tier exception request, while a clinical denial is fought with a prior-authorization appeal supported by a letter of medical necessity. Pull the plan's published golimumab coverage policy and quote its exact criteria, then attach records proving each requirement is met, including prior DMARD or biologic failures and required baseline screening. If step therapy through a preferred TNF inhibitor is the barrier, request a step-therapy exception citing prior failure, intolerance, or a documented contraindication to the preferred agent.
Simponi appeal letter template
Copy this Simponi appeal letter, fill in the brackets, and send it within your deadline. It is built on what overturns Tumor necrosis factor (TNF) inhibitor biologic denials.
[Date] [Your name] · Member ID [ID] · Rx claim # [#] [Insurer or PBM] - Appeals Department Re: Appeal of Simponi denial I am appealing the denial of Simponi (golimumab). I request that the denial be overturned and Simponi approved. 1. The denial. [Insurer] denied Simponi stating, verbatim: "[paste the exact denial reason from your letter]." 2. Medical necessity. Simponi is medically necessary for my condition. First identify which denial you received: a formulary or tier denial is fought with a formulary or tier exception request, while a clinical denial is fought with a prior-authorization appeal supported by a letter of medical necessity. Pull the plan's published golimumab coverage policy and quote its exact criteria, then attach records proving each requirement is met, including prior DMARD or biologic failures and required baseline screening. If step therapy through a preferred TNF inhibitor is the barrier, request a step-therapy exception citing prior failure, intolerance, or a documented contraindication to the preferred agent. 3. Step-therapy or formulary exception (if that was the reason): I have tried and failed [preferred drug(s)], with pharmacy records attached, or the preferred alternative is contraindicated because [reason]. I request a formulary or step-therapy exception. 4. My request. Approve Simponi within the timeframe required by law. If the denial is upheld, please provide the specific criteria used, the reviewing clinician's credentials, and external-review instructions. Attached: prescriber letter of medical necessity, pharmacy and prior-trial records, and supporting clinical notes. Sincerely, [Your name]
Want it built and filed for you? Use the free generator, or have Apellica do it.
Internal appeals: 30 days pre-service, 60 days post-service, 72 hours urgent. File within 180 days of the denial.
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- · The denial letter and your Explanation of Benefits (EOB)
- · Insurance ID, plan name, and the claim or prior-authorization number
- · Diagnosis with ICD-10 code and the prescriber's clinical notes
- · A record of treatments already tried and how they worked
Appealing a Simponi denial by insurer
The path depends on who manages your benefit. The most common:
Coverage runs through the pharmacy benefit. Appeal the coverage determination and, when the drug is non-formulary, file a formulary or tier exception with a provider attestation that covered alternatives are unsuitable.
Publishes detailed prior-authorization criteria. A denial usually means a criterion was not documented. Appeal through a coverage review, with a formulary exception for excluded drugs.
Administers many UnitedHealthcare and employer plans. Appeals and exceptions follow the plan's published PA criteria; expedited review exists for urgent cases.
Internal appeal first, then independent external review. Pre-service decisions are generally made within 30 days, urgent within 72 hours.
Internal appeals and external review; pharmacy denials often route through OptumRx criteria.
Independent state plans, so criteria vary. Match the appeal to your specific BCBS plan, internal appeal first, then external review.
Frequently asked questions
My plan denied Simponi and told me to try a different TNF inhibitor first. Can I still get it covered?
Yes, this is a step-therapy denial and it is appealable. If you have already tried and failed or could not tolerate the preferred drug the plan names, or you have a medical reason you cannot take it, submit a step-therapy exception with those records. If you have not tried the preferred agent, plans will usually require that trial first unless your prescriber documents a contraindication.
Does my prescriber have to put me on methotrexate with Simponi for it to be approved?
For rheumatoid arthritis, Simponi is FDA-approved for use in combination with methotrexate, and many plans require documented concurrent methotrexate or a documented reason you cannot take it. For psoriatic arthritis and ankylosing spondylitis, golimumab can be used alone, so concurrent methotrexate is generally not required. The appeal should match your indication to the plan's specific rule.
Is Simponi covered under my pharmacy benefit or my medical benefit?
Subcutaneous Simponi is self-injected and is usually covered under the pharmacy benefit, so denials come through prior authorization and formulary rules. The infusion product, Simponi Aria, is given in a clinic and is typically billed under the medical benefit, where site-of-care and buy-and-bill rules can apply. Knowing which benefit and which product applies determines where you file the appeal.
Simponi denied? We fight it for you.
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Start Your AppealThis page provides general information about appeal strategy. It is not legal or medical advice. Apellica is not a law firm. Outcomes depend on documentation, plan terms, and timing.