CurrentAetnaPolicy N/A

Orencia (abatacept) Injectable Medication Precertification Request

Precertification request form for Orencia (abatacept) injectable medication to collect patient, prescriber, clinical, dispensing, dosing, diagnosis, and justification information needed for Aetna prior authorization review. Used for start or continuation of therapy across multiple labeled and off-label indications.

Policy Summary

PayerAetna

PolicyOrencia (abatacept) Injectable Medication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionProviders must complete and legibly provide all required patient, insurer, prescriber, dispensing, product, diagnosis, and clinical information on the precertification form for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were identified for this precertification form.

Multi-indicationCovered Indications Captured on Form

Phone/FaxSubmission Methods

Part B requiredMedicare MA Form

Policy summary and purpose

This is Aetna's Orencia (abatacept) Injectable Medication Precertification Request form used to collect the patient, prescriber, dispensing, product/dosing, diagnosis, and clinical justification information needed to evaluate medical necessity for start or continuation of therapy across multiple labeled and off‑label indications including rheumatoid arthritis (RA), psoriatic arthritis (PsA), juvenile idiopathic arthritis (pJIA), prophylaxis of acute graft versus host disease (GVHD), chronic GVHD, and immune checkpoint inhibitor‑related toxicity. The form captures administrative details (insurance/member and prescriber credentials), dosing (loading and maintenance dose/frequency), place of administration/dispensing and administration CPT codes, and prompts for continuation or start dates as part of the precertification process.

Coding fields requested on the form

Administration code(s) (CPT) - reported field on formCPT

No codes listed

Diagnosis codes - primary/secondary/other ICD codes (requested on form)ICD-10

No codes listed

Billing Rule

Report administration CPT codes if applicable

When infusion or other administration occurs, include the appropriate administration CPT codes on the precertification form in the Administration code(s) (CPT) field; list any administration CPT codes requested on the form when applicable.

Administration CPT codes requested on form
Include codes when infusion/administration occurs

What providers must do when submitting the form

Documentation Required

Complete all form fields for precertification review

Provide and legibly complete all required patient, insurer, prescriber, dispensing, product, diagnosis, and clinical fields on the precertification form to allow Aetna to review medical necessity.

Patient (demographics, weight, height, allergies, contact)
Insurer (Aetna Member ID, group, other coverage, Medicare/Medicaid IDs)
Prescriber (credentials, address, phone/fax, NPI, specialty)
Dispensing/provider and place of administration details
Product (requested drug, dose, frequency)
Diagnosis (primary/secondary/other ICD codes)
Clinical information required for the indication

Prior Authorization

Precertification submission required

Submit precertification requests to Aetna Precertification Notification by phone or fax; Medicare Advantage Part B requests must use the Medicare request form.

Phone: 1-866-752-7021
Fax: 1-888-267-3277
Medicare Advantage Part B: use Medicare request form

Documentation Required

Indication-specific supporting documentation

Provide indication-specific supporting documentation such as prior therapy trials (for example methotrexate, NSAIDs, corticosteroids), evidence of intolerance or contraindication to prior agents, specialist consultation notes, tuberculosis testing results (PPD, IGRA, chest x-ray) when relevant, and dosing rationale consistent with compendia or current literature.

Prior therapy trials and outcomes
Intolerance or contraindication evidence
Specialist consultation notes
TB testing results and treatment status
Dosing rationale consistent with compendia/guidelines

Documentation Required

Dosing and age verification for GVHD prophylaxis

For GVHD prophylaxis, document the patient's age and verify the prescribed doses on the day before transplant and on Days 5, 14, and 28 do not exceed the age-based mg/kg limits or provide justification if limits are exceeded; see the form's GVHD prophylaxis dosing questions for the specific thresholds.

Document patient age
Confirm doses do not exceed age-based mg/kg limits or provide justification

Documentation Required

Continuation clinical response documentation

For continuation requests, provide objective measures demonstrating maintained or improved clinical response, such as joint counts, functional ability assessments, and percent improvement in signs/symptoms (e.g., tender/swollen joint counts, pain, or disability).

Number of affected/swollen/tender joints
Functional ability measures
Percent improvement from baseline (e.g., ≥20%)

Form background and definitions

The purpose of the precertification form is to document and justify medical necessity for Orencia across the listed indications by collecting indication‑specific information (diagnosis codes, prescriber specialty or consultation, prior therapy trials or intolerance, and dosing supported by compendia/guidelines) and by ensuring safety and appropriate administration. Safety and administration elements captured include questions about tuberculosis (TB) testing within 6 months with PPD/IGRA/chest x‑ray and results, infusion/administration safety screening (need for outpatient hospital setting due to prior severe infusion adverse events, venous access issues, behavioral/physical/cognitive impairments, or medical instability), and confirmation of specialist involvement for oncology/hematology or rheumatology as applicable.

Definitions

PPDtuberculosis skin test

IGRAinterferon-gamma release assay for tuberculosis

Document revision history

Current formLatest

CURRENT status: Precertification form for Orencia (abatacept) injectable medication used by Aetna to collect patient, prescriber, dispensing, dosing, diagnosis, and clinical information for start or continuation of therapy across multiple indications (RA, PsA, pJIA, GVHD prophylaxis, chronic GVHD, immune checkpoint inhibitor‑related toxicity). No dated revisions were provided in the brief; form content captures required items such as dosing, prior therapy trials, specialist consultation, TB testing, infusion safety, administration CPT codes, and indication‑specific checklists and age‑based GVHD dosing limits.

Policy Summary

PayerAetna

PolicyOrencia (abatacept) Injectable Medication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionProviders must complete and legibly provide all required patient, insurer, prescriber, dispensing, product, diagnosis, and clinical information on the precertification form for review.

SourceLink

On This Page

OpenPayer

Orencia (abatacept) Injectable Medication Precertification Request

Policy summary and purpose

Required clinical information captured on the precertification form

Key numeric thresholds and dosing checks referenced on form

Coding fields requested on the form

What providers must do when submitting the form

Form background and definitions

Document revision history