ModifiedCignaPolicy PSM010

Orencia Intravenous Preferred Specialty Management Policy for Individual and Family Plans

Defines Cigna's Preferred Specialty Management coverage and prior authorization criteria for Orencia intravenous for inflammatory conditions (rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis) for Individual and Family Plans.

Policy Summary

PayerCigna

PolicyOrencia Intravenous Preferred Specialty Management Policy for Individual and Family Plans

Policy CodePolicy PSM010

Change TypeMaterial updates to preferred product listings and addition of agents for JIA and PsA

Effective DateSep 1, 2025

Next Review DateSep 1, 2025

Key ActionSubmit prior authorization with prescription claims history (130-day look-back) or prescriber verification of ≥90 days prior Orencia subcutaneous use when claims are unavailable.

SourceLink

POLICY UPDATE CHANGES

New policy created with initial effective date and summary of changes.

Preferred product NDCs for certain adalimumab and biosimilar products were removed and prior trials of those NDCs count toward an adalimumab trial.

Additional preferred agents and clarifications were added for juvenile idiopathic arthritis and psoriatic arthritis.

6 monthsinitial approval duration

1 yearcontinuation approval duration

90 daysprescriber-verified prior use

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

130 daysclaims look-back

Coverage Criteria for Orencia (abatacept) Intravenous

Rheumatoid Arthritis - Initial Therapy

Covered when ALL of the following are met

RA Initial Therapy: Patient meets the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria

see standard prior authorization policy

RA Step 1 trials or exception: Patient has tried two of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR (documentation required) OR, according to the prescriber, the patient has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, or a demyelinating disorder

Trials of multiple products within the same product group count as ONE trial; examples and counting rules described in policy

Juvenile Idiopathic Arthritis - Initial Therapy

Covered when ALL of the following are met

JIA Initial Therapy: Patient meets the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria

see standard prior authorization policy

JIA Step 1 trials or exception: Patient has tried two of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq/Rinvoq LQ, or Xeljanz (documentation required) OR, according to the prescriber, the patient has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, or a demyelinating disorder

Trials of multiple products within the same product group count as ONE trial; examples and counting rules described in policy

Psoriatic Arthritis - Initial Therapy

Covered when ALL of the following are met

PsA Initial Therapy: Patient meets the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria

see standard prior authorization policy

PsA Step 1 trials or exception: Patient has tried two of Enbrel, an adalimumab product, Cosentyx, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Tremfya, or Xeljanz/XR (documentation required) OR, according to the prescriber, the patient has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, or a demyelinating disorder

Trials of multiple products within the same product group count as ONE trial; examples and counting rules described in policy

Continuation Therapy

Covered when ALL of the following are met

Current Orencia Therapy: Patient meets the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria

see standard prior authorization policy

Continuation supporting conditions: One of: (a) Patient has RA and has tried two of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR; (b) Patient has JIA and has tried two of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq/Rinvoq LQ, or Xeljanz; (c) Patient has PsA and has tried two of Enbrel, an adalimumab product, Cosentyx, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Tremfya, or Xeljanz/XR (documentation required); (d) According to the prescriber, patient has been established on Orencia intravenous for at least 90 days; (e) According to the prescriber, patient has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, or a demyelinating disorder; OR (f) Patient has been established on Orencia subcutaneous for at least 90 days and prescription claims history shows at least a 90-day supply dispensed within the past 130 days90 days; 130 days claims window

Verification in prescription claims history required or prescriber verification if claims unavailable; documentation required

Other Conditions

Covered when

Other Conditions: Patient meets the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria1 year

Approve Orencia IV initial therapy for duration as directed or 1 year for continuation; dosage, frequency, duration, and site of care must be clinically appropriate and supported by evidence-based literature

Initial and continuing therapy

Approve when ALL of the following are met:

Standard criteria: Patient meets the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria

Referenced standard policy criteria required

Verification of prior Orencia subcutaneous use: Verification via prescription claims history (preferred 130 days) OR prescriber attestation if claims unavailable (prescriber confirms ≥90 days of paid Orencia subcutaneous use)130 days claims window; 90 days prescriber-verified use

Exception allowed when claims history <130 days if prescriber verifies prior use and paid claims; samples or coupons not acceptable

Alternative products when subcriteria not met

If patient meets main criteria but not specific subcriterion 4Aii, reviewer may consider alternative products per indication:

Rheumatoid Arthritis alternatives: Actemra subcutaneous, Tyenne subcutaneous, Enbrel, adalimumab-adbm, Cyltezo, adalimumab-adaz, adalimumab-ryvk, Simlandi, Rinvoq, Xeljanz tablets, or Xeljanz XR

Use respective standard Inflammatory Conditions prior authorization policy criteria

Juvenile Idiopathic Arthritis alternatives: Actemra subcutaneous, Tyenne subcutaneous, Enbrel, adalimumab-adbm, Cyltezo, adalimumab-adaz, adalimumab-ryvk, Simlandi, Rinvoq, Rinvoq LQ, Xeljanz tablets, or Xeljanz oral solution

Use respective standard Inflammatory Conditions prior authorization policy criteria

Psoriatic Arthritis alternatives: Enbrel, adalimumab-adbm, Cyltezo, adalimumab-adaz, adalimumab-ryvk, Simlandi, Cosentyx, (and other agents listed in policy)

Use respective standard Inflammatory Conditions prior authorization policy criteria

Other Conditions

Other Conditions approval: Approve Orencia IV (initial therapy for duration as directed or 1 year for a patient continuing therapy) if patient meets the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria1 year

Dosage, frequency, duration, and site of care must be clinically appropriate and supported by evidence-based literature

Orencia (abatacept intravenous) is considered medically necessary only when the specified non-preferred product exception criteria are satisfied. Any exception other than those listed in the policy is not medically necessary and may be denied.

Receipt of free or manufacturer-supplied sample Orencia does not meet the policy requirements and does not satisfy any criteria for coverage under this policy.

Requests that fail to meet the specified non-preferred product exception criteria for Orencia intravenous are considered not medically necessary and are subject to denial.

Policy Identifier, Claims Look-back, and Key Values

Policy identifiermixed

PSM010

Coverage Policy Number (document identifier)

inv-13: Claims history look-back — 130 days

Claims history look-back period130 days look-back for prescription claims when verifying prior receipt of non-preferred product

When claims availableIf ≥130 days of prescription claims history exist, claims must show required prior use (e.g., 90 or 120 days) within the 130-day look-back period

When claims unavailableIf 130-day claims history is not available, prescriber verification is required (see prescriber-verified duration)

inv-14: Required prior use duration (when verification by prescriber) — 90 days

Required prior use duration (prescriber verification)Prescriber must verify at least 90 days of prior use when prescription claims history is unavailable

Prescriber attestation requirements

Provider Requirements, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization is required per the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria. Approvals for initial therapy and continuation therapy follow the durations specified in that policy and in these criteria. Receipt of sample product does not satisfy any criteria requirements for coverage.

Prior authorization required per standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria
Approval durations: initial therapy as directed in criteria (commonly 6 months for initial approvals); continuation therapy typically approved up to 1 year unless otherwise noted
Sample product receipt does not satisfy coverage criteria

Documentation Required

Claims/Prescriber Verification and Therapy Documentation

Verification of prescription claims history is required for continuation of therapy. If at least 130 days of prescription claims history is available, claims must demonstrate the patient received the non‑preferred or subcutaneous product for the required period (usually 90 or 120 days) within a 130‑day look‑back. If 130 days of claims history is not available, the prescriber must verify the patient has been receiving the product for the specified period (e.g., ≥90 days) and confirm the therapy was received via paid claims (not via samples, coupons, or other waivers). When documentation is requested to support trials or prior use, the prescriber should provide chart notes, prescription claims records, and/or prescription receipts.

Background on Orencia (abatacept) Intravenous

Orencia (abatacept IV) is indicated for inflammatory conditions including rheumatoid arthritis, juvenile idiopathic arthritis, and psoriatic arthritis. Multiple biologic and targeted therapies are available; this policy defines when Orencia intravenous (a non-preferred product) is allowed after trials of preferred agents or when documented exception criteria are met.

Definitions and Exception Criteria

inv-27: Exception criteria — Non-Preferred Product Exception Criteria

Scope of exception criteriaNon-Preferred Product Exception Criteria define when Orencia intravenous (non-preferred) may be approved for RA, JIA, and PsA initial therapy or continuation

Initial therapy approval durationApprove initial therapy for 6 months when the exception criteria are met for RA, JIA, and PsA

Documentation requirementDocumentation is required to support prior trials of required Step 1 agents as listed in the criteria

Continuation pathsContinuation may be approved if patient is established on Orencia IV ≥90 days, or on Orencia SC ≥90 days with claims showing ≥90-day supply within past 130 days, or other listed conditions

Alternative product pathwayIf standard criteria met but exception subcriteria not met, reviewer may consider alternative listed products per indication

Policy Summary

PayerCigna

PolicyOrencia Intravenous Preferred Specialty Management Policy for Individual and Family Plans

Policy CodePolicy PSM010

Change TypeMaterial updates to preferred product listings and addition of agents for JIA and PsA

Effective DateSep 1, 2025

Next Review DateSep 1, 2025

Key ActionSubmit prior authorization with prescription claims history (130-day look-back) or prescriber verification of ≥90 days prior Orencia subcutaneous use when claims are unavailable.

SourceLink

On This Page

Prescriber must confirm the patient received the product via paid claims (not samples, coupons, or waivers) when verifying prior use

Applies to continuation criteriaUsed to support continuation when claims cannot document the required prior subcutaneous or IV exposure

inv-15: Prescription claim history review window — 130 days

Prescription claim history review window130 days preferred review window for prescription claims history verification

Purpose of windowTo confirm that the patient received the non-preferred product for the specified duration (e.g., 90 days) within the 130-day look-back

Documentation acceptedPrescription claims records or receipts are acceptable documentation for claims-based verification

inv-16: Minimum prescriber-verified prior subcutaneous use when claims unavailable — 90 days

Minimum prescriber‑verified prior subcutaneous useAt least 90 days of prior Orencia subcutaneous use when claims history is unavailable (prescriber verification)

Verification must include paid claimsPrescriber must attest that prior use was via paid claims (not samples or coupons) when claims cannot be reviewed

Used for continuation and exception criteriaApplies when continuation criteria require established prior subcutaneous use but claims cannot be produced

Claims verification preferred: 130-day look-back to show required supply (e.g., 90 or 120 days) within 130 days
If claims history unavailable: prescriber verification required that patient received product for required period AND via paid claims (no samples/coupons)
Documentation acceptable: chart notes, prescription claims records, prescription receipts

Step Therapy

Step Therapy Positioning

Orencia intravenous is a Step 2 Non‑Preferred product requiring trials of two Step 1 preferred agents (specific preferred agents depend on the indication). Requests for non‑preferred product require documentation of trials of the directed Step 1 agents per the indication-specific criteria; if the patient meets the general criteria but not the indication-specific subcriteria, the reviewer may consider alternative products listed under the respective indication using the applicable standard Inflammatory Conditions Prior Authorization Policy criteria.

Orencia IV is Step 2 Non‑Preferred and directed to two Step 1 preferred agents
Step 1 preferred agents vary by indication (e.g., Enbrel, adalimumab products, tocilizumab SC, Cosentyx, Rinvoq, Xeljanz, etc.) — see indication-specific criteria
If indication-specific subcriteria are not met, reviewer may consider alternative agents listed for that indication using their standard prior authorization criteria

Step Therapy

Alternative Agents and Step Therapy

If the patient meets the standard Inflammatory Conditions - Orencia Intravenous criteria but does not meet the specific Step 2 exception subcriteria for continuing Orencia, the reviewer may evaluate coverage for alternate products appropriate to the indication. Examples of alternative agents to consider (per indication) include Actemra subcutaneous, Tyenne subcutaneous, Enbrel, specific adalimumab products (adalimumab-adbm, adalimumab-adaz, adalimumab-ryvk, Simlandi, Cyltezo, etc.), Rinvoq (and Rinvoq LQ), Xeljanz (tablets/ XR/solution), Cosentyx, Skyrizi SC, ustekinumab SC products, Tremfya, Cimzia, infliximab products, and Simponi — to be reviewed under their respective standard Inflammatory Conditions prior authorization policies. Documentation to support trials of these alternatives is required when noted.

Alternate agents may be considered when Step 2 subcriteria for Orencia IV are not met
Alternative products must be reviewed using their respective standard Inflammatory Conditions prior authorization policy criteria
Documentation of prior trials for alternatives is required when specified

Denial Risk

Nonpreferred Exception and Denial Risk

Requests that do not meet non‑preferred product exception criteria or the non‑preferred product exception documentation/verification requirements are considered not medically necessary and may be denied.

Non‑preferred exception criteria and documentation/verification requirements must be met or request may be denied
Sample product receipt does not satisfy criteria

inv-28: Verification of prior therapy — Requirement that prior receipt of Orencia subcutaneous be confirmed via prescription claims history (130 days preferred) or prescriber at...

Preferred verification methodVerification of prior Orencia subcutaneous use via prescription claims history is required (130 days preferred)

Alternate verification methodIf 130 days of claims are unavailable, prescriber must verify prior Orencia subcutaneous use and confirm at least 90 days of paid claims-based use (no samples/coupons)

Documentation to support verificationAcceptable documentation includes chart notes, prescription claims records, or prescription receipts per policy documentation requirements

ApplicationVerification applies to continuation criteria and exception evaluations when prior subcutaneous use is required