Cigna Orencia IV Coverage Policy Update

Coverage and Exception Criteria

Rheumatoid Arthritis - Initial Therapy (Orencia IV exception)

Approve for 6 months if ALL of the following are met

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

reference to standard PA policy

RA comparator trials or contraindication: Patient has tried TWO of: a tocilizumab subcutaneous product (e.g., Actemra SC, Avtozma SC, Tyenne SC), Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR (documentation required); OR prescriber documents heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, OR a demyelinating disorder

A trial of multiple products within the same drug class (e.g., multiple adalimumab products or multiple tocilizumab products) counts as ONE product; documentation of trials required.

Juvenile Idiopathic Arthritis - Initial Therapy (Orencia IV exception)

Approve for 6 months if ALL of the following are met

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

reference to standard PA policy

JIA comparator trials or contraindication: Patient has tried TWO of: a tocilizumab subcutaneous product (e.g., Actemra SC, Avtozma SC, Tyenne SC), Enbrel, an adalimumab product, Rinvoq/Rinvoq LQ, or Xeljanz (documentation required); OR prescriber documents heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, OR a demyelinating disorder

A trial of multiple products within the same drug class counts as ONE product; documentation of trials required.

Psoriatic Arthritis - Initial Therapy (Orencia IV exception)

Approve for 6 months if ALL of the following are met

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

reference to standard PA policy

PsA comparator trials or contraindication: Patient has tried TWO of: Enbrel, an adalimumab product, Otezla/Otezla XR, Rinvoq/Rinvoq LQ, Skyrizi SC, Sotyktu, an ustekinumab SC product, Taltz, Tremfya, or Xeljanz/XR (documentation required); OR prescriber documents heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, OR a demyelinating disorder

A trial of multiple products within the same drug class (e.g., multiple adalimumab or ustekinumab products) counts as ONE product; documentation of trials required.

Continuation of Therapy (Patients currently receiving Orencia SC or IV)

Approve for 1 year if ALL of the following are met

standard PA met: Patient meets the standard Inflammatory Conditions - Orencia Intravenous Policy criteria

reference standard PA policy

Comparator trials or established use: One of: patient has disease-specific trial history per policy (e.g., 2 trials of specified comparators) with documentation; OR patient has been established on Orencia IV for ≥90 days (per prescriber); OR prescriber documents heart failure, prior lymphoproliferative disorder, prior serious infection, or demyelinating disorder; OR patient has been established on Orencia SC ≥90 days with verification in prescription claims (≥90-day supply dispensed within past 130 days) or prescriber verification if claims unavailable

Documentation required for trials and verification; see policy for acceptable claims verification window and prescriber attestation rules.

Other Conditions

Other conditions: Approve Orencia intravenous (initial therapy for a duration as directed or 1 year for continuation) if patient meets the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria

catch-all provision

Non-Preferred Product Exception Criteria

Exception to Non-Preferred product coverage may be approved when specified clinical or treatment-history criteria are met.

Non-Preferred Product Exception - examples of qualifying criteria: At least one of: patient established on Orencia IV ≥90 days; patient has heart failure, prior lymphoproliferative disorder, prior serious infection, or demyelinating disorder; OR patient established on Orencia SC ≥90 days with verification via claims (≥90-day supply dispensed within past 130 days) or prescriber attestation if claims unavailable

Documentation required for verification; see policy for acceptable verification window (90-day supply within 130 days) and exceptions when claims not available.

Alternate Product Review when Exception Criterion Not Met

When patient meets standard Inflammatory Conditions Orencia IV prior authorization criteria but not the non-preferred exception criterion, certain alternative products may be reviewed under their respective standard prior authorization criteria.

Permitted alternative product review for Rheumatoid Arthritis: If patient meets standard PA but not the non-preferred exception, the following may be reviewed under standard RA criteria: Actemra SC, Avtozma SC, Tyenne SC, Enbrel, Humira (NDCs starting with 00074), adalimumab-adbm, Cyltezo, adalimumab-ryvk (NDCs starting with 82009), Simlandi, Rinvoq, Xeljanz (tablets/XR)

See policy product tables for full lists and condition-specific step placement.

Permitted alternative product review for Juvenile Idiopathic Arthritis: If patient meets standard PA but not the non-preferred exception, the following may be reviewed under standard JIA criteria: Actemra SC, Avtozma SC, Tyenne SC, Enbrel, Humira (NDCs starting with 00074), adalimumab-adbm, Cyltezo, adalimumab-ryvk (NDCs starting with 82009), Simlandi, Rinvoq, Rinvoq LQ, Xeljanz (tablets or oral solution)

Permitted alternative product review for Psoriatic Arthritis: If patient meets standard PA but not the non-preferred exception, the following may be reviewed under standard PsA criteria: Enbrel, Humira (NDCs starting with 00074), adalimumab-adbm, Cyltezo, adalimumab-ryvk (NDCs starting with 82009), Simlandi, Otezla (and Otezla XR), Rinvoq, Rinvoq LQ, Skyrizi SC, Sotyktu, Stelara SC, Imuldosa SC (NDCs starting with 69448), Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC

Other Conditions

Coverage for other inflammatory conditions

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

Orencia intravenous is designated a Non-Preferred (Step 3) product and may only be approved as a non-preferred product when the policy's specific non-preferred product exception criteria are met. Any exception request that does not meet the specified non-preferred product exception criteria is considered not medically necessary and will be denied.

For requests that rely on prior use of Orencia subcutaneous to meet a non-preferred product exception, verification is required in prescription claims history that a ≥90-day supply of Orencia subcutaneous was dispensed within the past 130 days. If claims history cannot be verified, the prescriber must attest that the patient has been receiving Orencia subcutaneous for at least 90 days and confirm the use was via paid claims (i.e., not samples, coupons, or other waivers). If neither claims verification nor prescriber attestation is provided per these requirements, the claims-verification requirement may block exception approval unless other exception criteria are met.

Orencia intravenous is considered medically necessary as a non-preferred product only when the policy's Non-Preferred Product Exception Criteria are satisfied. The exception criteria require meeting the standard Inflammatory Conditions – Orencia Intravenous prior authorization criteria plus one of the qualifying clinical or treatment-history conditions (for example, specified prior trials of preferred agents, documented contraindications such as heart failure, or established use of Orencia IV/SC as defined in the policy). Requests that do not meet these exception criteria do not qualify as medically necessary for Orencia IV.

Requests lacking required documentation to verify prior trials of preferred/step agents, or lacking prescriber attestation when claims are unavailable, may be considered not medically necessary. The policy specifies that documentation (e.g., chart notes or prescription claims records) is required to support trials of preferred products; similarly, verification of prior Orencia subcutaneous use requires either claims evidence (90-day supply within the last 130 days) or an explicit prescriber attestation when claims are not available.

Codes and Product Identifiers

Referenced NDC prefixes for comparatorsNDC

NDCs starting with 00074	Humira (specific NDC prefix referenced for preferred products and alternatives)
NDCs starting with 82009	adalimumab-ryvk and related products (referenced)
NDCs starting with 69448	Imuldosa subcutaneous (referenced)

No codes listed

Notable NDC prefixes mentionedNDC

NDCs starting with 82009	adalimumab-ryvk (Preferred adalimumab product NDC prefix)
NDCs starting with 69448	Imuldosa subcutaneous (Preferred ustekinumab subcutaneous product NDC prefix)
NDCs starting with 00074	Humira (example listed NDC prefix)

No codes listed

Prescription claims history verification window

Verification windowPrescription claims history look-back period is 130 days for verifying prior dispensing (e.g., 90-day supply within the past 130 days)

Alternate verificationIf 130 days of claims history are unavailable, prescriber verification is acceptable provided the prescriber attests the patient received paid claims (no samples/coupons)

Use for continuation approvalsContinuation of therapy approvals rely on claims verification within this 130-day window to confirm prior use of non-preferred subcutaneous products or Orencia SC

Prior Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required per the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy. Prior authorization is required for Orencia intravenous and for requests seeking an exception to non-preferred product requirements.

Prior authorization required for Orencia intravenous per standard policy.
Prior authorization required for exceptions to Non-Preferred Product requirements.

Step Therapy

Step Therapy Placement

Orencia Intravenous is designated as a Step 3 Non-Preferred product and generally requires trials of Preferred (Step 1) and/or Step 2a products directed per condition prior to approval. Step placement directs whether one or two prior Product trials are required (e.g., Step 3 directed to TWO Step 1 or 2a products).

Step 3 Non-Preferred: Orencia Intravenous — directed to TWO Step 1 or 2a products.
Trials must follow the Step 1 and Step 2a product lists by condition (Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, Psoriatic Arthritis).

Background and Clinical Context

Orencia (abatacept) administered by intravenous infusion is an approved therapeutic option for inflammatory conditions including rheumatoid arthritis, juvenile idiopathic arthritis, and psoriatic arthritis. Multiple biologic and targeted synthetic disease-modifying antirheumatic drugs are available for these conditions; this policy places Orencia intravenous as a Step 3 Non-Preferred option that generally requires prior trials of preferred Step 1 and/or Step 2a products or meeting specified clinical exception criteria.

Key Definitions

Orencia Intravenous

DrugOrencia (abatacept) — intravenous infusion

Indications (policy context)Used for inflammatory conditions including rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), and psoriatic arthritis

FormulationIntravenous infusion product (distinct from subcutaneous formulation)

Established on therapy

DefinitionEstablished on therapy: per prescriber, patient has been on Orencia IV or SC for at least 90 days

Claims verification for Orencia SCFor patients established on Orencia subcutaneous, prescription claims must show at least a 90-day supply dispensed within the past 130 days (verification in prescription claims history required)

Policy Revision History

2026-05-01policy_effectiveLatest

Policy relocated criteria and product listings from PSM006 into a new legacy drug list policy; multiple product-list and step-assignment updates were applied during the relocation (operational relocation of product lists).

2026-01-01revision

New policy created for Legacy Drug List Plans by relocating criteria previously in PSM006; Hyrimoz NDCs starting with 61314 were removed from Preferred Products and other counting-rule adjustments were made (Cimzia added for JIA).

2025-04-15

OpenPayer

Orencia Intravenous Preferred Specialty Management Policy for Legacy Prescription Drug Lists

Coverage and Exception Criteria

Codes and Product Identifiers

Prior Authorization, Step Therapy, and Documentation Requirements

Background and Clinical Context

Key Definitions

Policy Revision History