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Inflammatory Conditions - Orencia Intravenous Preferred Specialty Management Policy for Legacy Prescription Drug Lists
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Governs prior authorization and preferred-product step therapy rules for Orencia intravenous (abatacept IV) across inflammatory conditions (RA, JIA, PsA) for Cigna-administered plans.
adalimumab-aaty was added as a preferred product for all conditions.
References to Xeljanz were modified to reference the generic product tofacitinib for Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, and Psoriatic Arthritis.
Sotyktu was added as a Step 1 Preferred Product for Psoriatic Arthritis.
Coverage Criteria for Orencia (abatacept) Intravenous
Non-Preferred Product Exception Criteria (Orencia IV)
Orencia intravenous is considered medically necessary when the following non-preferred product exception criteria are met.
Applies to initial non-preferred exception approvals per section 1
Referenced standard PA criteria required for all approvals
Trials of multiple products within the same drug class (e.g., multiple adalimumab products or multiple tocilizumab products) count as one product; trials of both formulations of the same agent (e.g., tofacitinib and tofacitinib XR or Rinvoq and Rinvoq LQ) count collectively as one product. Documentation required as noted in policy.
Step 1/2a examples include Actemra subcutaneous, Avtozma subcutaneous, Tyenne subcutaneous, Enbrel, select adalimumab NDCs and biosimilars, Rinvoq, and generic tofacitinib formulations (lists vary by indication).
See policy for full lists and counting rules for trials.
Multiple pathway options (a–f) allow continuation coverage; documentation or claims verification required where specified.
Initial and Continuation Therapy
Covered when ALL of the following are met
Orencia IV may be approved as initial therapy for a directed duration (typically 6 months when exception criteria met) or for 1 year for continuation therapy per the policy.
Orencia intravenous is a Step 3 non‑preferred product that may be approved only under the specific Non‑Preferred Product Exception Criteria enumerated in this policy. Any other exception beyond the specified non‑preferred product exception criteria is considered not medically necessary.
Use of the listed non‑preferred products (examples include specific adalimumab products, etanercept/Enbrel, Rinvoq, and generic tofacitinib formulations) without meeting the stated exception criteria or without documented trials of the required preferred Step 1/Step 2a agents may exclude approval. The policy requires documentation of prior trials or a prescriber‑documented, indication‑specific rationale before Orencia IV will be authorized.
If a requested exception does not satisfy the enumerated non‑preferred product exception criteria, the request is considered not medically necessary. The policy explicitly lists acceptable exception pathways and required supporting documentation; exceptions falling outside those pathways will not be approved.
When prior authorization criteria or the defined non‑preferred product exception criteria are not met, a determination of not medically necessary will follow. This includes situations where required trials of preferred products or the required documentation of those trials are not provided.
Coding and Product Identifiers
| NDCs starting with 00074 | Humira NDCs indicated as preferred adalimumab products |
| NDCs starting with 82009 | Certain adalimumab-ryvk NDCs |
| NDCs starting with 69448 | Imuldosa/ustekinumab subcutaneous NDCs |
| NDCs starting with 00074 | Humira NDC prefix referenced as non-preferred |
| NDCs starting with 82009 | adalimumab-ryvk NDC prefix referenced as non-preferred |
| NDCs starting with 69448 | Imuldosa subcutaneous NDC prefix listed as preferred ustekinumab product |
Provider Actions, Prior Authorization & Documentation
Prior authorization required
Prior authorization is required per the standard Inflammatory Conditions - Orencia Intravenous Prior Authorization Policy criteria; non-preferred product exception approvals follow the policy's step-therapy and documentation requirements.
Initial and continuation approval durations
Prior authorization is required; Orencia IV may be approved as initial therapy for a directed duration (e.g., 6 months under the non‑preferred exception) and approvals for patients currently receiving Orencia are provided for up to 1 year when criteria are met.
Step therapy — trial of preferred products required
The program requires trials of Preferred Products (Step 1 and Step 2a lists) when clinically appropriate before approving non‑preferred products such as Orencia IV; exceptions require documentation of prior trials or specified clinical reasons.
Step 1 and Step 2a preferred products (examples & recent additions)
Step therapy applies: providers must document trials of the listed Step 1 and Step 2a preferred products for the patient’s condition before Orencia IV (a Step 3 non‑preferred product) will be approved except where exception criteria apply.
- Step 1 examples (condition-specific): Enbrel; adalimumab products (e.g., Humira NDCs starting with 00074); agents added for PsA: Sotyktu.
- Step 2a examples: adalimumab biosimilars/adalimumab-aaty; Skyrizi SC; Imuldosa SC (NDCs starting with 69448); Avtozma SC added for RA and JIA.
- Recent additions: Sotyktu (Step 1 for PsA), Avtozma SC (Step 2a for RA and JIA), and adalimumab-aaty added as preferred for all conditions.
Provide written documentation to verify prior trials
When documentation is required, the prescriber must provide written evidence supporting trials of other products, which may include chart notes, prescription claims records, and/or prescription receipts and must include patient‑specific identifying information.
- Verification in prescription claims history may be required when specified (130‑day look‑back window applies).
- If claims history is unavailable, the prescriber must verify prior use and that use was via paid claims (not samples/coupons).
Documentation must show prior trials or allowed clinical rationale
Documentation submitted with a prior authorization request must demonstrate the specific prior trials or prescriber rationale required by the policy’s preferred and non‑preferred product exception criteria for the applicable diagnosis.
- For non‑preferred exception approvals, documentation must show trials of two specified agents (e.g., two of tocilizumab SC, Enbrel, an adalimumab product, Rinvoq, or tofacitinib/XR) or prescriber‑stated contraindications listed in the criteria.
Use covered diagnosis/procedure codes or claim may be denied
Claims for services not accompanied by covered diagnosis or procedure codes under this Coverage Policy will be denied as not covered; when billing, providers must use the most appropriate covered codes as of the submission date.
Non‑compliant requests will be denied/not medically necessary
Requests that do not meet the standard prior authorization criteria or the policy’s non‑preferred product exception criteria (including required trials of preferred products) will be denied or considered not medically necessary.
- Non‑preferred product approvals require meeting the enumerated exception criteria; any other exception is considered not medically necessary.
Background
Orencia (abatacept) intravenous infusion is one of multiple biologic and targeted therapies available to treat inflammatory conditions such as rheumatoid arthritis, juvenile idiopathic arthritis, and psoriatic arthritis. This policy addresses the IV formulation’s placement as a non‑preferred (Step 3) option relative to listed preferred subcutaneous and oral agents and defines the exception and prior‑authorization pathways required for coverage.
Definitions and Terminology
Revision Details
adalimumab-aaty was added as a preferred product for all conditions.
Avtozma SC was added as a Step 2a preferred product for Rheumatoid Arthritis and Juvenile Idiopathic Arthritis.
Avtozma (SC) was added as a Step 2a product for Rheumatoid Arthritis and Juvenile Idiopathic Arthritis (initial entry recorded 2026-04-09).
Imuldosa subcutaneous (NDCs starting with 69448) was added as a preferred ustekinumab subcutaneous product for Psoriatic Arthritis.
Xeljanz oral solution was added as a Step 2a agent for Psoriatic Arthritis and tablet references were removed from Xeljanz in the preferred products listing.
Otezla XR was added to the Step 1 Preferred Products list for Psoriatic Arthritis; a trial of either Otezla or Otezla XR collectively counts as one product.
References to Xeljanz were modified to the generic product name tofacitinib for Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, and Psoriatic Arthritis (notation of criteria updates through 2026-08-01).
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