Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Orencia requires pre-authorization.

2)    Orencia (Abatacept) is an injectable medication used in the treatment of severe Rheumatoid arthritis, psoriatic arthritis, and juvenile rheumatoid arthritis.

3)    Orencia will generally be used only where other medications have been tried and have failed to result in or maintain improvement.

4)    Orencia is not used at the same time as TNF inhibitors, such as Remicade (Infliximab), Enbrel (Etanercept), or Humira (Adalimumab).

Abatacept is considered medically necessary in the treatment of:

 1)    Adults 18 years of age and older with moderately to severely active rheumatoid arthritis (M05.00-M05.9, M06.80-M06.9) with

a.    At least 6 swollen or tender joints AND

b.    At least 45 minutes of morning stiffness AND

c.    Elevated ESR or CRP unless taking corticosteroids AND

d.    Inadequate response to at least one DMARD (i.e. methotrexate) AND

e.    Inadequate response to at least two of Humira, Cimzia, Simponi, Xeljanz/XR, and Rinvoq.

2)    Children age 6 years and older with moderate or severely active polyarticular juvenile rheumatoid arthritis (M08.20-M08.3) or juvenile idiopathic arthritis (M08.89) with an inadequate response to Humira.

3)    Adults 18 years of age or older with moderate to severe psoriatic arthritis with

a.    Greater than 3 swollen and tender joints AND

b.    Inadequate response to at least one DMARD (i.e. methotrexate) AND

c.    Inadequate response to at least 2 of Humira, Cimzia, Tremfya, Stelara, and Simponi.

Codes Used In This BI:

As a specialty drug, Orencia is limited to no more than a 30 day supply per fill.

1. Bristol-Meyers Squib prescribing information at: http://www.bms.com/cgi- bin/anybin.pl?sql=select%20PPI%20from%20TB_PRODUCT_PPI%20where%20 PPI_SEQ=111&key=PPI
2. Food and Drug administration approval letter at: http://www.fda.gov/cder/foi/appletter/2005/125118rev2.pdf
3. Fries JF, Spitz P, Kraines RG, and Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum. 1980; 23(2):137-145.
4. Genant HK, Jiang Y, Peterfy C, Lu Y, Re´dei J, Countryman PJ. Assessment of rheumatoid arthritis using a modified scoring method on digitized and original radiographs. Arthritis Rheum. 1998; 41(9):1583-1590.
5. Pincus T, Summey JA, Soraci SA Jr, Wallston KA, Hummon NP. Assessment of patient satisfaction in activities of daily living using a modified Stanford Health Assessment Questionnaire. Arthritis Rheum. 1983; 26(11):1346-1353.
6. Ware JE Jr, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. J Clin Epidemiol. 1998; 51(11):903-912.
7. Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Mariotto A, Feuer EF, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2001, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2001/. Accessed 2004.
8. Ringold S, Weiss PF, Beukelman T, et al.  2013 Update of the 2011 American College of Rheumatology Recommendations for the Treatment of Juvenile Idiopathic Arthritis. Arthritis & Rheumatism. 2013; 65:2499-2512
9. Clinical Pharmacology. Accessed September 19, 2017.