HMSA Orencia prior auth Coverage & Policy Update

Indication-specific Coverage Criteria

Indication-specific initial and continuation criteria

Coverage is considered when specific indication-based AND/OR conditional criteria are met; the form branches by diagnosis and by whether the request is for initiation (new start) or continuation of therapy.

General prerequisites: Provider completes and submits the prior authorization form with patient identifiers, applicable ICD-10 diagnosis code, patient demographics (weight/height where requested), prescriber NPI/contact details, and documents rheumatology/oncology consultation when required; fax submission to CVS Caremark Specialty Programs (1-866-237-5512).

See form instructions and header fields; fax number referenced on multiple pages.

TB screening for biologics with TB risk: Patient has had tuberculosis screening (e.g., TST or IGRA) within the prior 12 months and results are documented; if positive, documentation of latent TB treatment initiation/completion or active TB is provided.within 12 months

TB screening logic is part of routine biologic pre-treatment evaluation on the form.

Rheumatoid arthritis - initial therapy pathway: Patient has moderately to severely active rheumatoid arthritis; requested drug is prescribed by or in consultation with a rheumatologist; patient has failed a 3-month trial of methotrexate monotherapy at a maximum titrated dose of >= 15 mg per week or has documented inability to tolerate methotrexate; and the patient has had inadequate response to methotrexate in combination with at least one other conventional synthetic DMARD (e.g., hydroxychloroquine and/or sulfasalazine) per the specified trial durations, or there is documented contraindication/intolerance to required csDMARD(s). Prior receipt of another biologic or targeted synthetic agent for RA within the past 120 days (excluding samples or manufacturer patient assistance) excludes approval via the new-start pathway.MTX >=15 mg/week; 3 months; 30 months for certain combination criterion; 120 days lookback

See stepwise RA questions and timing/dose thresholds (chunks 4-9).

Rheumatoid arthritis - continuation of therapy: This request is for continuation of therapy with the requested drug AND the patient is currently receiving the drug (not via samples or manufacturer assistance) AND the provider documents a positive clinical response since starting treatment, for example substantial disease activity improvement (e.g., at least 20% improvement in tender/swollen joint counts, pain, or disability) or maintained low disease activity.>=20% improvement example

Continuation questions and examples of clinical response are captured in the continuation section (chunks 4 and 5).

Polyarticular/Articular juvenile idiopathic arthritis (pJIA) - initial therapy: Patient has moderately to severely active polyarticular/articular juvenile idiopathic arthritis AND is age >= 2 years AND the requested drug is prescribed by or in consultation with a rheumatologist; for new starts, the patient must have had an inadequate response to methotrexate or another conventional synthetic DMARD at adequate dose/duration or documented intolerance/contraindication to required csDMARD(s).>=2 years; csDMARD trials generally 3 months

pJIA-specific branching and age requirement appear in the JIA section (chunks 3 and 9).

Polyarticular/Articular juvenile idiopathic arthritis (pJIA) - continuation: For continuation requests, the provider must document clinical improvement in joint counts or functional status since initiation of the requested drug (per continuation logic).

Continuation definition and requirement to show response are in the continuation section and definitions (chunks 4 and planner definitions).

Psoriatic arthritis - initial and continuation: Patient with psoriatic arthritis (age criteria as applicable) is prescribed/consulted by rheumatology or dermatology; continuation requires documented clinical response; new-start pathway requires prior trial of csDMARD(s) unless there is severe disease, enthesitis, or documented contraindication/intolerance to csDMARD therapy per the form questions.

PsA branching is listed among diagnosis choices and follows similar csDMARD requirement logic (chunk 3 and planner criteria).

Chronic graft-versus-host disease (cGVHD) - initial and continuation: Prescribed by or in consultation with an oncologist/hematologist; initial therapy requires prior inadequate response to systemic corticosteroids or documentation of contraindication/intolerance where specified; continuation requires documentation of clinical response on therapy.

cGVHD appears as a distinct diagnostic branch on the form (chunk 3) with oncology/hematology prescriber expectations.

Immune checkpoint inhibitor-related toxicity: Prescribed by or in consultation with an oncologist/hematologist for ICI-related toxicity; documentation must indicate inadequate response to systemic corticosteroids or contraindication to steroids where required and note any special combination therapy considerations (e.g., concomitant agents for overlap syndromes).

ICI-toxicity is a listed indication and the form requests oncologist involvement and steroid-failure documentation (chunk 3 and planner summary).

Prophylaxis of acute graft-versus-host disease (aGVHD) - initial and continuation: Patient is age >= 2 years; prescribed by or in consultation with an oncologist/hematologist; indication is prophylaxis of acute GVHD in the HSCT setting (from matched or 1 allele-mismatched unrelated donor where specified); therapy is used in combination with required agents (e.g., calcineurin inhibitor and methotrexate) when specified on the form.>=2 years

Prophylaxis of aGVHD is a diagnosis branch with HSCT donor and combination therapy conditions noted (chunk 3 and planner references).

sJIA handling: Systemic juvenile idiopathic arthritis (sJIA) is not processed through the standard form; requests for sJIA should follow the Criteria Exception Policy per the form listing.

sJIA is directed to a separate Criteria Exception Policy on the diagnosis selection (chunk 3).

Systemic juvenile idiopathic arthritis (sJIA) is not processed through this standard prior authorization form. Instead, coverage requests for sJIA are handled via a separate Criteria Exception Policy; the form directs the user to that policy when sJIA is selected as the diagnosis on the intake page.

For new-start requests, the form requires documentation of prior treatment with conventional synthetic DMARDs or a documented contraindication/intolerance to those agents. Requests that do not document required csDMARD trials (including dose/duration where specified) or that fail to show a contraindication/intolerance when applicable may be considered not medically necessary or incomplete and are at risk for denial under the step-therapy logic.

Diagnosis, Dosing, and Lookback Coding

Requested diagnosis codingICD-10

ICD-10

The form requests the applicable ICD-10 diagnosis code for the patient's condition (blank field provided).

inv-05: Methotrexate minimum titrated dose

Methotrexate minimum titrated dose>= 15 mg per week

Context in RA initial therapyUsed as the MTX monotherapy trial before considering biologic; requirement tied to 3-month trial duration (see csDMARD trial duration).

Alternative pathwaysIf MTX intolerance is documented, other csDMARD trials or combination strategies are considered per form logic.

inv-06: Prior biologic lookback

Prior biologic lookback period120 days

ScopeApplies to prior receipt of biologic or targeted synthetic drug indicated for moderately to severely active RA (excludes samples or patient assistance program use).

Provider Submission and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. The completed HMSA/MCD prior authorization form must be faxed to CVS Caremark Specialty Programs at 1-866-237-5512. Failure to submit the completed form to CVS Caremark Specialty Programs (fax 1-866-237-5512) may result in denial of the request. For questions regarding the prior authorization process, contact CVS Caremark at 1-808-254-4414; for Specialty Customer Care (eligibility, copay, delivery) call CaremarkConnect at 1-800-237-2767.

Fax: 1-866-237-5512
CVS Caremark PA inquiries: 1-808-254-4414
Specialty Customer Care / CaremarkConnect: 1-800-237-2767

Documentation Required

Required Documentation on Prior Authorization Form

The prior authorization form must include key patient and provider identifiers and clinical details to support the request. Provide: patient name, patient ID, date of birth, patient phone number, patient weight (kg) and height (ft/in), ICD-10 diagnosis code, indication/diagnosis selected on the form, dispensing site (e.g., office, pharmacy, outpatient hospital), administration site if applicable, physician name, specialty, NPI, office telephone and fax, and documentation of whether the drug is being provided via samples or a manufacturer's patient assistance program. Approvals may be subject to dosing limits in accordance with FDA labeling, accepted compendia, and evidence-based guidelines.

Definitions and Continuation Criteria

inv-13: Continuation of therapy

Definition of continuation requestsApplies when the patient is currently receiving the requested drug (including via standard dispensing; excludes samples/PAP in some questions).

Required response assessmentDocumentation that the patient has achieved or maintained a positive clinical response (e.g., low disease activity or improvement in signs/symptoms) since starting the drug.

Specific measures of improvementImprovement may be evidenced by decreased number of active/swollen/painful joints or improved functional ability as documented on the form.

inv-14: Inadequate response

Inadequate response definition (RA)Failure to achieve low disease activity after a 3-month trial of methotrexate monotherapy at a maximum titrated dose of at least 15 mg/week.

Inadequate response after combination therapy

Policy Background

This prior authorization form is used to support coverage decisions for abatacept (Orencia) and related biologic and targeted therapies across multiple immune-mediated indications. It collects the diagnosis (ICD-10), prior treatment history (including csDMARD trials and biologic use), relevant biomarker and tuberculosis screening information, and prescriber specialty to permit indication-specific determinations for both initial and continuation therapy.

OpenPayer

Prior authorization criteria for abatacept (Orencia) and related biologic/targeted therapies

Indication-specific Coverage Criteria

Diagnosis, Dosing, and Lookback Coding

Provider Submission and Documentation Requirements

Definitions and Continuation Criteria

Policy Background