ModifiedCignaPolicy PSM018

Inflammatory Conditions - Orencia Intravenous Preferred Specialty Management Policy for Legacy Prescription Drug Lists

Defines Cigna's preferred specialty management criteria for Orencia intravenous (abatacept IV) including prior authorization, step therapy, and continuation requirements for inflammatory conditions (RA, JIA, PsA) for applicable legacy prescription drug lists.

Policy Summary

PayerCigna

PolicyOrencia Intravenous Preferred Specialty Management Policy for Legacy Prescription Drug Lists

Policy CodePolicy PSM018

Change TypeMaterial updates and consolidationpreferred product list revisions

Effective DateMar 1, 2026

Next Review Date

Key ActionSubmit prior authorization with documentation of prior therapies and, when required, verification of at least 90 days of prior Orencia subcutaneous use (claims or prescriber attestation with evidence of paid claims).

SourceLink

POLICY UPDATE CHANGES

New policy established by relocating criteria from the Employer Plans policy (PSM006) to a Legacy Drug List policy with updated criteria.

Preferred product lists were updated (examples: removal/addition of specific NDC blocks and specific biosimilar examples).

For Psoriatic Arthritis, multiple agents were added to Step 1 and Step 2 lists (e.g., Otezla XR, Bimzelx, Cosentyx additions; Xeljanz oral solution added to Step 2a).

Added verification paths for patients established on Orencia subcutaneous for at least 90 days including claims history or prescriber attestation when claims unavailable.

6 monthstypical initial approval duration for new starts

1 year

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Coverage Criteria for Orencia Intravenous (abatacept IV)

Non-Preferred Product Exception Criteria — Initial Therapy by Indication

Orencia intravenous is considered medically necessary when the Non-Preferred Product Exception Criteria below are met. Any other exception is considered not medically necessary.

General requirement for all exception approvals

Indication-specific additional requirement
- Rheumatoid Arthritis (Initial Therapy): Patient has tried TWO of the following: a tocilizumab subcutaneous product (e.g., Actemra 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.
- Juvenile Idiopathic Arthritis (Initial Therapy): Patient has tried TWO of the following: a tocilizumab subcutaneous product (e.g., Actemra SC, Tyenne SC), Enbrel, an adalimumab product, Rinvoq or Rinvoq LQ, or Xeljanz [documentation required]; OR prescriber documents heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, OR a demyelinating disorder.
- Psoriatic Arthritis (Initial Therapy): Patient has tried TWO of the following: Enbrel, an adalimumab product, Otezla/Otezla XR, Rinvoq/Rinvoq LQ, Skyrizi SC, 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.

Approval duration: If criteria met, approve for 6 months for initial therapy.

Continuation Therapy / Currently Receiving Orencia

Criteria for patients currently receiving Orencia (subcutaneous or intravenous).

Continuation of therapy

Acceptable continuation conditions (examples): One of: (a) Prior trials as specified for each indication (two Step 1/2a products) [documentation required]; (b) Patient has been established on Orencia intravenous for at least 90 days (per prescriber); (c) Prescriber documents heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, OR a demyelinating disorder; OR (d) Patient has been established on Orencia subcutaneous for at least 90 days with verification by prescription claims history (>=90-day supply dispensed within past 130 days) OR, if claims unavailable, prescriber verification that patient received >=90 days of SC therapy via paid claims (not samples/coupons).

Approval duration for current therapy: If continuation criteria met, approve for 1 year.

Initial or switch therapy coverage criteria

Covered when ALL of the following are met

Established subcutaneous to IV transfer: Patient has been established on Orencia subcutaneous for at least 90 days and prescription claims history indicates at least a 90-day supply was dispensed within the past 130 days OR if claims history is not available, prescriber verifies at least 90 days of subcutaneous use and that use was via paid claims (not samples/coupons).90 days within 130-day lookback

Exception allowed if prescriber attests and paid claims exist

Clinical risk factors: According to the prescriber, the patient has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, OR a demyelinating disorder (these support selection of IV formulation).

Product-specific step therapy: If the patient meets the standard Inflammatory Conditions criteria but not specific product criteria, trials of listed preferred agents for the specific indication (RA, JIA, PsA) are required as per the standard Inflammatory Conditions Prior Authorization Policy or the specific agent lists in this policy.

Orencia intravenous is considered medically necessary only when the Non-Preferred Product Exception Criteria are met. Any exception that does not meet these specified criteria is not medically necessary.

No additional exclusions are explicitly stated in this portion of the policy.

Requests for Orencia intravenous that do not meet the defined Non-Preferred Product Exception Criteria are considered not medically necessary.

When prior subcutaneous Orencia use is required for exception consideration, requests that lack verification of that prior therapy may be denied. Verification requires prescription claims showing at least a 90‑day supply dispensed within the past 130 days, or, if claims are not available, a prescriber attestation that the patient received Orencia subcutaneous for at least 90 days and that use was via paid claims (not samples or coupons). Requests without such claims or prescriber verification are considered not medically necessary.

Coding and Product Identifiers

Referenced product NDC prefixesNDC

NDCs starting with 00074	Humira (specific adalimumab NDC prefix)
NDCs starting with 82009	adalimumab-ryvk and related NDC prefix

Preferred / Non-Preferred NDC examplesNDC

NDCs starting with 00074	Humira examples cited as Preferred
NDCs starting with 82009	adalimumab-ryvk specified as Preferred
NDCs starting with 61314	Hyrimoz NDCs removed from Preferred products

inv-10: Prescription claims look-back

Look-back window130 days

Verified exposure within look-backAt least 90-day supply dispensed within the prior 130 days

Alternative when claims unavailablePrescriber verification that patient received ≥90 days of therapy and that use was via paid claims (not samples/coupons)

PurposeUsed to confirm continuation of Non-Preferred subcutaneous therapy when reviewing prior authorization requests

inv-11: Established subcutaneous therapy verification window

Minimum established durationAt least 90 days of Orencia subcutaneous therapy

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization and step requirement

Prior authorization is required for all medications in this program. In addition to prior authorization, step therapy requirements apply: patients must trial Preferred Product(s) (Step 1) as specified in the policy prior to approval of Non‑Preferred Products unless an exception in the criteria is met.

All requests must meet the relevant standard Prior Authorization Policy criteria referenced in this policy.
Continuation approvals are generally provided for 1 year (1 month = 30 days) unless otherwise noted.

Prior Authorization

Prior authorization and product verification

When requesting a Non‑Preferred Product, the prescriber must provide verification that the patient has previously received the product when continuation of therapy is the basis for the request. Verification may be via prescription claims history or prescriber attestation when claims history is unavailable.

If the patient has ≥130 days of prescription claims history on file, claims history must document the specified supply (typically 90 or 120 days) within a 130‑day look‑back period.

Definitions and Background

Orencia (abatacept) administered intravenously is an approved biologic option for inflammatory arthritides, including rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), and psoriatic arthritis (PsA). This policy places Orencia IV within a step‑therapy framework where approval for the non‑preferred IV formulation requires meeting the standard Inflammatory Conditions prior authorization criteria and, when specified, documented trials of preferred agents or verification of prior Orencia subcutaneous use.

inv-23: Orencia intravenous

DefinitionAbatacept administered by intravenous infusion for inflammatory arthritides

Indications referencedRheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), and psoriatic arthritis (PsA)

Policy contextOrencia intravenous is managed within the Inflammatory Conditions step therapy framework and subject to prior authorization

Related requirementApproval may require trials of preferred products or meeting Non-Preferred Product Exception Criteria as specified in the policy

Policy Summary

PayerCigna

PolicyOrencia Intravenous Preferred Specialty Management Policy for Legacy Prescription Drug Lists

Policy CodePolicy PSM018

Change TypeMaterial updates and consolidationpreferred product list revisions

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

Step Therapy

Step therapy placement

Step therapy placement is defined in the Preferred and Non‑Preferred Products table: Preferred (Step 1) products must generally be tried before Step 2a/2b or Step 3 Non‑Preferred products. Certain Non‑Preferred products are directed to specific Step 1 agents as noted.

Step 2a Non‑Preferred products are typically directed to ONE Step 1 Product (specific directs listed per agent).
Step 3 Non‑Preferred products (e.g., Orencia IV) are directed to TWO Step 1 or 2a products and may require documentation to support trials.

Step Therapy

Step therapy for non-preferred product requests

For Non‑Preferred product requests that are subject to step therapy, if the step requirement is not met the request will be reviewed for possible approval only if applicable exception criteria are met and required documentation is provided.

Orencia intravenous as a Non‑Preferred product requires meeting the exception criteria (e.g., prior trials of specified agents or presence of listed comorbidities) to be approved.
If criteria for exception are not met, reviewers may consider alternate Step 1 or Step 2a product requests under their respective standard prior authorization criteria.

Documentation Required

Documentation of prior trials

When trials of Preferred Products are required by the criteria, the prescriber must supply documentation of those trials when noted as [documentation required]. Acceptable documentation includes chart notes, prescription claims records, and prescription receipts and must include patient‑specific identifying information.

A trial of multiple products within the same biologic class (e.g., multiple adalimumab products) counts as one Preferred Product trial unless otherwise specified.
Documentation is required for certain Step 3 Non‑Preferred approvals (see policy table) and for demonstrating prior trials of Step 1 or Step 2 agents.

Documentation Required

Verification when claims history unavailable

When prescription claims history cannot be verified (less than 130 days available), the prescriber’s verification must state that the patient has been receiving the product for the required period and that the product was obtained via paid claims; samples, coupons, or other waivers do not satisfy verification.

Prescriber attestation should specify duration of use (e.g., ≥90 days) and affirm paid claims dispensation.
Claims‑based verification is required when ≥130 days of prescription claims history is available; otherwise prescriber verification is acceptable per above conditions.

Documentation Required

Verification of prior Orencia subcutaneous therapy

Requests for continuation of Orencia subcutaneous require verification that the patient has been established on Orencia subcutaneous for at least 90 days. Verification must be supported by prescription claims history showing a 90‑day supply dispensed within the past 130 days, or by prescriber verification when claims history is unavailable (with confirmation of paid claims dispensation).

Orencia subcutaneous continuation criterion: ≥90 days on therapy with claims verification (90‑day supply within 130‑day look‑back) OR prescriber verification if claims unavailable.
If prescriber verifies use due to lack of claims, they must confirm the patient did not rely on samples, coupons, or other waivers to obtain the product.

inv-24: Established on Orencia subcutaneous

Established on Orencia subcutaneous (term)Patient has received Orencia subcutaneous for at least 90 days

Verification requirementClaims history must show a 90-day supply dispensed within the prior 130 days or, if claims unavailable, prescriber attestation plus evidence that therapy was via paid claims

Purpose in policyUsed as one acceptable condition for continuation of therapy or for transfer from subcutaneous to intravenous formulation

Documentation acceptedPrescription claims records or prescriber verification; documentation must include patient-identifying information