Colorado Rocky Mountain Health Plans Orencia Prior Auth

Coverage Criteria

Rheumatoid Arthritis - Initial Authorization

Covered when ALL of the following are met

RA initial authorization: (1) Diagnosis of moderately to severely active rheumatoid arthritis

RA prior therapy option: (2) One of the following: (a) BOTH: i) History of failure to a 3-month trial of one non-biologic DMARD at maximally indicated doses unless contraindicated (document drug, date, duration) AND ii) History of failure, contraindication, or intolerance to two preferred products (document drug, date, duration) (preferred products include one of the preferred adalimumab products, Cimzia (certolizumab), Enbrel (etanercept), Rinvoq (upadacitinib), Simponi (golimumab), Xeljanz/Xeljanz XR (tofacitinib)); OR (b) Patient has been previously treated with a targeted immunomodulator FDA-approved for RA as documented by claims or medical records (document drug, date, duration)

RA additional requirements: (3) Patient is not receiving Orencia in combination with another targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, adalimumab products, Xeljanz, Olumiant, Rinvoq)

Prescriber requirement: (4) Prescribed by or in consultation with a rheumatologist

Manufacturer sample note: Patients established on therapy solely via a manufacturer-supplied sample or Bristol-Myers Squibb Co-Pay Program assistance must meet initial authorization criteria as if new to therapy

Rheumatoid Arthritis - Reauthorization

Reauthorization — Covered when ALL of the following are met

RA reauthorization: (1) Documentation of positive clinical response to Orencia therapy

RA reauthorization no combo: (2) Patient is not receiving Orencia in combination with another targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, adalimumab products, Xeljanz, Olumiant, Rinvoq)

Authorization duration: Authorization will be issued for 12 months

Polyarticular Juvenile Idiopathic Arthritis

Covered when ALL of the following are met

JIA initial: (1) Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis

JIA no combo: (2) Patient is not receiving Orencia in combination with another targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, adalimumab products, Xeljanz, Olumiant, Rinvoq)

JIA prescriber: (3) Prescribed by or in consultation with a rheumatologist

JIA reauthorization: Reauthorization requires documentation of positive clinical response to Orencia therapy and patient not receiving Orencia in combination with another targeted immunomodulator

Psoriatic Arthritis - Initial Authorization

Covered when ALL of the following are met

PsA initial diagnosis: (1) Diagnosis of active psoriatic arthritis

PsA prior therapy options: (2) One of the following: (a) BOTH: i) History of failure to a 3-month trial of methotrexate at maximally indicated dose unless contraindicated (document date and duration) OR patient previously treated with a targeted immunomodulator FDA‑approved for PsA as documented by claims/medical records; AND ii) History of failure, contraindication, or intolerance to two preferred products (document drug, date, duration) (preferred list includes one of the preferred adalimumab products, Cimzia, Cosentyx, Enbrel, Rinvoq, Simponi, Skyrizi, one of the preferred ustekinumab products, Tremfya, Xeljanz/Xeljanz XR); OR (b) BOTH: patient is <18 years of age AND history of failure/contraindication/intolerance to one preferred ustekinumab product or Enbrel (etanercept) (document date and duration)

PsA current user option: If relying on current Orencia therapy: patient is currently on Orencia as documented by claims history or medical records (document date and duration); patients established solely via manufacturer sample must meet initial criteria as new to therapy

Initial Therapy

Covered when ALL of the following are met (initial authorization logic with nested options):

Age or prior-failure branch: Either: (a) patient meets first branch OR (b) BOTH: patient is less than 18 years of age AND history of failure, contraindication, or intolerance to one of the preferred ustekinumab products or Enbrel (etanercept) (document date and duration of trial)

Represents alternative pathways for different age groups and prior therapy requirements

Current therapy branch: If relying on current Orencia therapy to bypass steps: patient is currently on Orencia as documented by claims history or submission of medical records (document date and duration); patient must not have been established only via manufacturer-supplied sample

Submission of medical records required if claim history not available

No combination therapy: Patient is not receiving Orencia in combination with another targeted immunomodulator (policy lists examples)

Combination therapy with listed agents is exclusionary

Reauthorization

Reauthorization is approved when ALL of the following are met:

Clinical response: Documentation of positive clinical response to Orencia therapy is required for reauthorization

No combination therapy: Patient is not receiving Orencia in combination with another targeted immunomodulator (examples listed)

Authorization duration note: Authorization will be issued for 12 months (state mandates may apply; Connecticut, Kentucky, and Mississippi may require a 30-day trial)

Use of Orencia (abatacept) concurrently with another targeted immunomodulator is an explicit exclusion across indications. The policy requires that the patient is not receiving Orencia in combination with another targeted immunomodulator as a condition of approval for initial authorization, reauthorization, and continuation in all covered disease states.

Providers should document that Orencia will be used as monotherapy or only with allowed concomitant non-targeted agents; any plan to co-administer Orencia with another biologic or targeted immunomodulator will render the request noncompliant with the coverage criteria and may result in denial.

The policy lists specific examples of targeted immunomodulators that must not be used in combination with Orencia. Examples include but are not limited to Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), adalimumab products, Xeljanz (tofacitinib), Olumiant (baricitinib), and Rinvoq (upadacitinib); for certain indications the list is expanded to include agents such as ustekinumab, Skyrizi (risankizumab), Tremfya (guselkumab), Cosentyx (secukinumab), Taltz (ixekizumab), and Otezla (apremilast).

Requests documenting concurrent use of Orencia with any of these listed agents are excluded/contraindicated for approval per the policy language and will be denied unless the combination is discontinued and monotherapy criteria are met.

Provider Actions & Requirements

Denial Risk

Provider Action: Prior Authorization Required / Denial Risk

Prior authorization is required for subcutaneous Orencia (abatacept). Coverage may be denied if the patient is receiving Orencia in combination with another targeted immunomodulator.

Coverage may be denied if patient is receiving Orencia in combination with another targeted immunomodulator (examples include Enbrel [etanercept], Cimzia [certolizumab], Simponi [golimumab], adalimumab products, Xeljanz [tofacitinib], Olumiant [baricitinib], Rinvoq [upadacitinib], ustekinumab, Skyrizi [risankizumab], Tremfya [guselkumab], Cosentyx [secukinumab], Taltz [ixekizumab], Otezla [apremilast]).

Documentation Required

Provider Action: Evidence & Documentation of Prior / Current Therapy

Document prior therapy and current therapy to demonstrate eligibility for Orencia under step/step-up requirements. For initial authorization, document drug name, date, and duration of trials or prior treatments; claims history or medical records may be used to verify prior biologic or current Orencia use. Patients established on Orencia via manufacturer samples or co-pay assistance must meet initial authorization criteria as if new to therapy unless claims/records document ongoing therapy.

Initial Therapy Criteria

Initial therapy

Initial authorization requirements vary by indication but generally require diagnosis plus specified prior therapy trials or documentation of prior targeted agent use.

General initial: Diagnosis of the specified condition and patient is not receiving Orencia in combination with another targeted immunomodulator; prescribed by or in consultation with a rheumatologist when specified

Prior therapy options: Either: documented failure/intolerance/contraindication to specified non-biologic DMARD(s) (e.g., methotrexate) AND to two preferred products (document drug, date, duration), OR previous treatment with a targeted immunomodulator as documented by claims/medical records

Initial Therapy

Initial authorization requirements for Orencia

Pediatric/prior-failure option:

Continuation / Reauthorization Criteria

Continuation therapy

Reauthorization/continuation requirements

Continuation - positive response: Documentation of positive clinical response to Orencia therapy

Continuation - no combo therapy: Patient is not receiving Orencia in combination with another targeted immunomodulator

Reauthorization / Continuation Therapy

Reauthorization/continuation

Positive response: Documentation of positive clinical response to Orencia therapy is required for reauthorization

Authorization issued for 12 months.

Step Therapy Requirements

Step therapy requirement	Details / examples
Trials of specified non-biologic DMARD(s) required
History of failure to a 3‑month trial of one non‑biologic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine) at maximally indicated doses unless contraindicated (document drug, date, and duration of trial)

Step therapy edits / preferred products	Notes
Step therapy edits have been updated over time to specify preferred products (examples have included adalimumab products, ustekinumab products, Cosentyx, Enbrel, Rinvoq, Xeljanz, Tremfya, Skyrizi)
Refer to drug coverage tools for the current list of preferred products; historical change log documents multiple updates 2020–2025 and the 2024–2025 modifications that removed or changed specific examples (see Change Control and References)

Definitions

Concomitant targeted immunomodulator use

DefinitionUse of Orencia together with other targeted immunomodulators, biologic DMARDs, or JAK inhibitors is not recommended and is treated as exclusionary for concurrent therapy.

Examples of excluded agentsEtanercept (Enbrel), Certolizumab (Cimzia), Golimumab (Simponi), Adalimumab products, Tofacitinib (Xeljanz), Baricitinib (Olumiant), Upadacitinib (Rinvoq)

Policy effectPatient must not be receiving Orencia in combination with another targeted immunomodulator to meet initial authorization or reauthorization criteria.

Documentation noteIf relying on current Orencia therapy to satisfy prior‑therapy requirements, submit claims history or medical records; manufacturer samples do not establish current-user status.

Targeted immunomodulator

Definition

Background

Orencia (abatacept) is a selective T‑cell co‑stimulation modulator indicated for moderately to severely active rheumatoid arthritis in adults, for polyarticular juvenile idiopathic arthritis in patients 2 years of age and older, and for active psoriatic arthritis in patients 2 years of age and older. The policy notes that concomitant use with other immunosuppressive targeted immunomodulators is not recommended and is treated as an exclusion to coverage.

When requesting authorization, providers must ensure the member is not receiving Orencia in combination with another targeted immunomodulator; the policy provides specific example agents to clarify the exclusion and requires prescriber specialty consultation (rheumatologist or dermatologist where specified) as part of initial authorization criteria.

Quantity Limits

Orencia (abatacept) — supply limits

DrugOrencia (abatacept)

Quantity limit noteSupply limits may be in place.

Site-of-care noteIntravenous infusion is typically covered under the medical benefit; refer to the medical benefit drug policy for Orencia.

Site of Care

Billing Rule

Infusion (IV) administration is billed to the medical benefit

Intravenous infusion (Orencia IV) is typically covered under the medical benefit; refer to the UnitedHealthcare medical benefit drug policy for Orencia for billing and site‑of‑care guidance.

Supply/quantity limits may apply per additional clinical rules.

OpenPayer

Orencia (abatacept) subcutaneous prior authorization

Coverage Criteria

Provider Actions & Requirements

Initial Therapy Criteria

Continuation / Reauthorization Criteria

Step Therapy Requirements

Definitions

Background

Quantity Limits

Site of Care