Colorado Rocky Mountain HP Orencia Prior Auth

Coverage Criteria

Initial Therapy — Rheumatoid Arthritis

Approved when ALL of the following are met

RA initial: Patient has diagnosis of moderately to severely active rheumatoid arthritis

RA prior therapy path: One of the following paths: (a) history of failure to a 3-month trial of one non-biologic DMARD at maximally indicated doses unless contraindicated OR prior treatment with a targeted immunomodulator documented by claims/medical records; AND history of failure, contraindication, or intolerance to two preferred products (document drug, date, and duration of trials) OR (b) patient is currently on Orencia therapy as documented by claims history or medical records and has not relied on a manufacturer-supplied sample or Bristol-Myers Squibb Orencia Co‑Pay assistance to establish current use

Document drug name, dates, and duration of trials; current-user documentation must attest no sample/co‑pay assistance used to establish therapy

RA monotherapy restriction: Patient is not receiving Orencia in combination with another targeted immunomodulator (examples: Enbrel, Cimzia, Simponi, adalimumab products, Xeljanz, Olumiant, Rinvoq)

RA prescriber: Prescribed by or in consultation with a rheumatologist

Reauthorization — Rheumatoid Arthritis

Approved when ALL of the following are met

RA reauth response: Documentation of positive clinical response to Orencia therapy

RA reauth monotherapy: Patient is not receiving Orencia in combination with another targeted immunomodulator (examples listed in policy)

Authorization issued for 12 months

Initial Therapy — Polyarticular JIA

Approved when ALL of the following are met

JIA initial diagnosis: Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis

JIA monotherapy: Patient is not receiving Orencia in combination with another targeted immunomodulator (examples listed in policy)

Prescribed by or in consultation with a rheumatologist; authorization issued for 12 months

Reauthorization — Polyarticular JIA

Approved when ALL of the following are met

JIA reauth response: Documentation of positive clinical response to Orencia therapy

JIA reauth monotherapy: Patient is not receiving Orencia in combination with another targeted immunomodulator (examples listed in policy)

Initial Therapy — Psoriatic Arthritis

Approved when ALL of the following are met

PsA initial diagnosis: Diagnosis of active psoriatic arthritis

PsA prior therapy path: One of the following: (a) history of failure to a 3-month trial of methotrexate at maximally indicated dose unless contraindicated OR prior treatment with a targeted immunomodulator documented by claims/medical records; AND failure, contraindication, or intolerance to two preferred products (document drug, date, and duration) OR (b) patient <18 years with history of failure/contraindication/intolerance to one preferred ustekinumab product or ustekinumab/Enbrel as specified

Document drug name, dates, and duration of trials

PsA monotherapy: Patient is not receiving Orencia in combination with another targeted immunomodulator (examples listed in policy)

PsA prescriber: Prescribed by or in consultation with a rheumatologist or dermatologist as specified

Initial Therapy

Covered when the following structured criteria are met for initial therapy

Initial paths

Path A: Both of the following: 1) Patient is less than 18 years of age; 2) History of failure, contraindication, or intolerance to one of the preferred ustekinumab products or Enbrel (etanercept) with documented date and duration of trial.
Path B: Both of the following: i) Patient is currently on Orencia therapy as documented by claims history or submission of medical records (document date and duration of therapy); ii) Patient has not received a manufacturer supplied sample at no cost in the prescriber's office, or any form of assistance from the Bristol-Myers Squibb Orencia Co‑Pay Program to establish current user status.
Patients established on therapy via manufacturer sample or co‑pay assistance must meet initial authorization criteria as new to therapy.

General monotherapy restriction: Patient is not receiving Orencia in combination with another targeted immunomodulator (examples listed in policy)

Coverage will not be approved when the member is receiving Orencia concomitantly with another targeted immunomodulator. Requests where Orencia is prescribed in combination with agents such as Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), adalimumab, JAK inhibitors (e.g., Xeljanz/tofacitinib, Olumiant/baricitinib, Rinvoq/upadacitinib), or other specified biologic targeted immunomodulators will not meet criteria and will be denied.

Use of Orencia in combination with another targeted immunomodulator is excluded from approval. Examples listed in the policy include, but are not limited to: Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), adalimumab, ustekinumab and other IL‑12/23 or IL‑23 agents (e.g., Skyrizi/risankizumab, Tremfya/guselkumab), IL‑17 agents (e.g., Cosentyx/secukinumab, Taltz/ixekizumab), and oral targeted agents such as Xeljanz (tofacitinib), Olumiant (baricitinib), and Rinvoq (upadacitinib). Documentation showing concomitant use with any of these targeted immunomodulators will result in denial of the request.

Initial Therapy — Drug-specific Rules

Initial Therapy — drug-specific

Initial therapy coverage rules differ by indication but generally require diagnosis, prior therapy trials or prior targeted immunomodulator history

initial_general: Diagnosis of the indicated condition and patient is not receiving Orencia in combination with another targeted immunomodulator; prescribed by or in consultation with a rheumatologist (or dermatologist for PsA as specified)

Document prescriber specialty

prior_paths: Either: (1) trial/failure of specified non‑biologic DMARD(s) or methotrexate and failure of specified preferred agents (document drug, date, duration); OR (2) prior use of an FDA‑approved targeted immunomodulator for the indication (document drug, date, duration); OR (3) current documented Orencia use with required documentation and no manufacturer sample/co‑pay assistance used to establish current use

Providers must document prior therapies including drug name, dates, and duration; claims history or medical records acceptable

Initial therapy — Initial therapy criteria and bypass conditions

Reauthorization and Continuation Criteria

Reauthorization / Continuation — Reauthorization requires ongoing clinical benefit and absence of concurrent targeted immunomodulator therapy.

Reauthorization requires ongoing clinical benefit and absence of concurrent targeted immunomodulator therapy.

continuation: Documentation of positive clinical response to Orencia; patient not receiving concomitant targeted immunomodulator

Authorization issued for 12 months

Continuation therapy / current-user documentation

Continuation / current-user bypass rules

Current Orencia users: Patients currently on Orencia documented by claims history or medical records may bypass some step therapy requirements if documentation includes date and duration of therapy; cannot be established by manufacturer sample or co‑pay assistance alone.

Document date and duration of therapy; attest that sample/co‑pay assistance was not used to establish current use

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required — Initial authorization requirements

Prior authorization required. Initial authorization will be approved only when diagnosis-specific criteria and the documented prior-therapy trials below are met; authorization is generally issued for 12 months.

Initial authorization requires meeting diagnosis-specific criteria and documentation of prior therapies (drug name, date, and duration of trial).
If the patient is currently on Orencia, provide claims history or medical records documenting date and duration of therapy. Patients established on Orencia via manufacturer samples or Bristol-Myers Squibb Orencia Co-Pay Program assistance must meet initial criteria as if new to therapy.
Prescriber requirement: prescribed by or in consultation with a rheumatologist (and for certain indications may include dermatologist).

Documentation Required

Documentation Required — Prior therapy documentation

Document prior therapies precisely. The submission must include drug name, dates, and duration of each prior trial to support step-therapy and preferred product failure requirements.

Step Therapy and Preferred Products

Requirement	Details
Requirement	History of failure, contraindication, or intolerance to two of the listed preferred biologic/targeted products documented with drug name, date, and duration of trial; applies as a required pathway prior to Orencia for certain indications (e.g., rheumatoid arthritis and psoriatic arthritis).
Documentation	Provider must document the specific agents tried, dates, and duration of each trial. Current Orencia users may bypass this if claims or medical records demonstrate ongoing therapy (cannot be established solely by manufacturer samples or copay assistance).

Preferred step product examples / group	Policy note / action
One of the preferred adalimumab products; Cimzia (certolizumab); Cosentyx (secukinumab); Enbrel (etanercept); Rinvoq (upadacitinib); Simponi (golimumab); Skyrizi (risankizumab-rzaa); One of the preferred ustekinumab products; Tremfya (guselkumab); Xeljanz/Xeljanz XR (tofacitinib)	Failure, contraindication, or intolerance to the applicable preferred step product(s) must be documented (drug, date, duration). For the current list of preferred products (including specific preferred adalimumab and ustekinumab products), reference the drug coverage tools. Authorization issued for 12 months; state mandates may apply.

Quantity Limits

Orencia (abatacept) — Supply limits and site rules

Quantity limit statusSupply limits may be in place for Orencia (abatacept)

Limit frequencyPer policy: supply limits may apply (see pharmacy benefit management tools)

Reference for administration billingIV infusion typically billed under the medical benefit — see medical benefit drug policy

Site-of-Care and Benefit Assignment

Billing Rule

IV infusions billed under medical benefit — see medical benefit drug policy

Intravenous infusions of Orencia are typically billed under the medical benefit; providers should refer to the UnitedHealthcare Medical Benefit Drug Policy for Orencia for administration and billing guidance.

Definitions

Current user

DefinitionA patient currently on Orencia therapy as documented by claims history or submission of medical records

Documentation requirementClaims history or medical records must document date and duration of therapy to qualify as a current user

Manufacturer assistance exclusionPatients established via manufacturer-supplied samples or Bristol-Myers Squibb Orencia Co-Pay Program assistance must meet initial authorization criteria as new to therapy

Related prescriber noteCurrent users should have therapy prescribed by or in consultation with a rheumatologist where indicated

Intravenous infusion site

Administration benefitIntravenous (IV) infusions of Orencia are typically covered under the medical benefit

Background

Abatacept (Orencia) is a selective T‑cell costimulation modulator indicated for moderately to severely active rheumatoid arthritis in adults, polyarticular juvenile idiopathic arthritis in patients 2 years and older, and active psoriatic arthritis in patients 2 years and older. Clinical guidance and the policy advise against concomitant use with other targeted immunomodulators or JAK inhibitors; such combinations are not recommended and are excluded from coverage under this policy. Intravenous administration is typically billed under the medical benefit; refer to the medical benefit drug policy for administration and site-of-care details.

OpenPayer

Orencia (abatacept) subcutaneous prior authorization

Coverage Criteria

Initial Therapy — Drug-specific Rules

Reauthorization and Continuation Criteria

Provider Actions and Documentation Requirements

Step Therapy and Preferred Products

Quantity Limits

Site-of-Care and Benefit Assignment

Definitions

Background