Golimumab (Simponi and Simponi Aria) and Medicare

Start with the finding that matters

We went through every 2026 Medicare drug plan formulary CMS publishes and counted. Simponi, the self-injection, is covered by 45 of 5,518 plans — under 1%. Among standalone drug plans, the number is zero.

So the $2,100 Part D cap, which sounds like it protects you, is theoretical for nearly every Medicare patient on this medication. The real-world numbers agree: about 33,000 Medicare beneficiaries get Simponi Aria through Part B, and only about 3,700 get Simponi through Part D.

In practice, if you are on Medicare and taking golimumab, you are almost certainly on the infusion — and the rest of this page is about making that as affordable as possible.

What the infusion costs

Simponi Aria is covered by Part B. You pay 20% with no yearly limit. The dose depends on your weight, and it is given every eight weeks after the first two doses.

A Medicare supplement policy changes this completely. It covers the 20%, so you pay the $283 Part B deductible and then nothing. For someone on this medication, that is worth well over $2,000 a year.

Simponi Aria comes in 50 mg vials. If your dose does not divide evenly into whole vials, Medicare is billed for the remainder — which is why 80 kg costs noticeably more than 75 kg. The infusion visit is billed separately and you pay 20% of that too.

Which route is approved for what

The two forms are not interchangeable on paper, and the differences are easy to miss:

• Ulcerative colitis is the shot only. Simponi Aria is not approved for it, so someone with UC cannot move to the infusion.
• Juvenile arthritis is the infusion only. Simponi Aria is approved from age 2; the shot is not approved for it.
• Rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis are approved for both.

Cheaper versions are approved but not yet on sale

In May 2026 the FDA approved the first golimumab biosimilars — one for the shot and one for the infusion — and both were approved as interchangeable, which is the strongest designation the FDA gives.

They are not on the market yet, no price has been published, and there is a legal dispute over the launch. Their approved conditions are also narrower than the originals. So this is worth knowing about and not worth planning around. If your infusion is expensive, ask again in a year.

Approvals and being made to try something else first

Original Medicare requires no prior authorization for Simponi Aria given in a doctor’s office, and cannot require you to fail a different medication first.

Medicare Advantage plans vary wildly on this one, more than for any other drug on this site. One national insurer’s 2026 policy lists Simponi Aria as non-preferred for rheumatoid arthritis and requires you to try a long list of self-injectable medications first. Another plan lists it as a preferred first-line option.

That difference is worth real money and real delay, and it is not visible from the plan brochure. If you are choosing an Advantage plan and you are on this medication, this is the specific thing to ask about by name.

If a request is denied, appeal. Across Medicare Advantage in 2024, 81% of appealed denials were overturned, and only about one in nine was ever appealed.

Things that surprise people

• The names are confusingly similar. Simponi and Simponi Aria are billed through completely different parts of Medicare. If someone quotes you a price, check which one they mean.
• The copay card does not work if you have Medicare. Federal law prohibits it, and that includes Medicare Advantage and Medigap.
• The manufacturer’s foundation does serve Medicare patients, for both products, based on income. For someone facing $2,800 a year with no supplement, this is the first call to make.
• Where you get infused changes the price. A hospital outpatient department adds a facility fee that an office or independent infusion suite does not.
• Your dose follows your weight. Gaining or losing enough to cross a vial boundary changes what you pay.

Free help, from someone who is not paid a commission

• Washington: SHIBA — insurance.wa.gov/shiba or 1-800-562-6900
• Any other state: SHIP — shiphelp.org
• Compare plans — medicare.gov/plan-compare
• Extra Help — ssa.gov/medicare/part-d-extra-help

Why isn’t my infusion covered by the $2,100 cap?

Because the $2,100 cap only applies to Part D, and an infusion is paid by Part B. The cap Congress created covers drugs you pick up and take yourself. A medication a nurse or doctor gives you is paid under Part B instead, where you owe 20% of the cost every time and there is no annual ceiling at all.

It is the same Medicare, often the same drug, and frequently the same disease. The rulebook is chosen by who puts the medicine in you. Almost everything written about the cap leaves this out, so people on infusions read that their costs are now limited, and then the bills keep coming.

A worked example. If Medicare’s approved amount for a year of your infusions is $18,000, you owe about $3,600 — this year, next year, and every year you stay on it. The $2,100 cap does not apply to any of it.

Four things do put a ceiling on Part B costs:

• A Medicare supplement (Medigap) policy, which pays the 20% for you. This is the main one, and the window to buy one closes six months after you enroll in Part B in most states.
• A Medicare Advantage plan’s yearly out-of-pocket maximum, which applies to everything the plan covers — though it comes with prior authorization attached.
• QMB, a Medicare Savings Program that eliminates the 20% entirely. This is the one people are not told about — and note that Extra Help, which people are told about, does nothing for a Part B drug.
• Full Medicaid, or retiree coverage that pays after Medicare.

Related

• Medicare and your medication
• Why your medication needs permission first
• Secukinumab (Cosentyx) and Medicare — the same two-route question, where the home version is widely covered
• Where you get infused changes the bill — the same infusion costs more at a hospital, and the bill nobody warns you about

Where these figures come from

1. Simponi and Simponi Aria prescribing information — FDA, via DailyMed. Simponi: 50 mg subcutaneously once monthly for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis; separate regimen for ulcerative colitis. Simponi Aria: 2 mg/kg intravenously at weeks 0 and 4, then every 8 weeks; supplied in 50 mg vials. Ulcerative colitis is approved for the subcutaneous form only; polyarticular juvenile idiopathic arthritis for the intravenous form only.
2. Medicare payment limit for intravenous golimumab (J1602): $11.035 per mg — CMS Part B ASP pricing file effective July 1 – September 30, 2026. Annual figures assume 6.5 maintenance infusions, or 8 infusions in the first year, with billing for medication discarded from partially used vials.
3. Part B annual deductible $283 and 20% coinsurance with no annual limit for 2026 — CMS, “2026 Medicare Parts A & B Premiums and Deductibles”; Social Security Act §1833(a). Part D annual out-of-pocket cap $2,100 — CMS Final CY2026 Part D Redesign Program Instructions.
4. Formulary coverage of Simponi 50 mg: 45 of 5,518 plans (0.8%), and 0 of 367 standalone prescription drug plans — analysis of the CMS Basic Drugs Formulary File, released July 31, 2026. Of the plans that do cover it, 97.8% require prior authorization and 40 of 45 place it on the specialty tier. Method checked against Enbrel and Humira, both covered by over 99% of plans.
5. Medicare spending 2024: Simponi Aria (J1602) $330 million across 33,452 beneficiaries under Part B; Simponi $185 million across 3,667 beneficiaries under Part D — CMS Medicare drug spending dashboards.
6. First golimumab biosimilars approved May 15, 2026, both as interchangeable products, with narrower approved conditions than the originals — FDA. Launch timing, price and the related litigation were unresolved at the time of writing.
7. No prior authorization program in Original Medicare covers physician-administered drugs — CMS, Prior Authorization and Pre-Claim Review Initiatives. Step therapy permitted for Medicare Advantage Part B drugs — 42 CFR §422.136. The contrasting preferred and non-preferred examples are taken from two insurers’ published 2026 Part B drug lists.
8. Medicare Advantage appeal rates and outcomes for 2024 (11.5% of denials appealed, 80.7% overturned) — KFF analysis of CMS data, 2026.
9. Copay assistance is prohibited for federal healthcare program beneficiaries — federal Anti-Kickback Statute, 42 U.S.C. §1320a-7b; Janssen CarePath program terms. The Johnson & Johnson Patient Assistance Foundation accepts Medicare beneficiaries subject to income limits.

About this page

Written and reviewed by Alison Bays, MD, MPH, board-certified rheumatologist. Figures are current for 2026 and were last checked in August 2026.

This is educational information, not advice — not medical, legal, financial or insurance advice, and not a substitute for talking to your doctor or your plan. Nothing is sold here. No insurance is sold here, no plan is recommended, and neither this page nor its author is paid by any insurance company, plan, pharmaceutical manufacturer or broker. This page is not affiliated with, endorsed by, or connected to Medicare, the Centers for Medicare & Medicaid Services, or any government agency.

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