ModifiedUnitedHealthcarePolicy 2025 P 1075-14

UnitedHealthcare Pharmacy Clinical Pharmacy Programs

UnitedHealthcare pharmacy prior authorization policy for subcutaneous Orencia (abatacept) covering initial authorization and reauthorization criteria for rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, and psoriatic arthritis; includes concomitant therapy exclusions and duration of approval. IV formulation covered under medical benefit and referenced to medical policy.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Pharmacy Clinical Pharmacy Programs

Policy CodePolicy 2025 P 1075-14

Change TypeAnnual review; minor updates and clarifications

Effective DateApr 1, 2025

Next Review Date

Key ActionPrior authorization is required; initial and reauthorization approvals will be issued for 12 months when criteria are met.

POLICY UPDATE CHANGES

Annual review 1/2025 updated examples with no change to clinical intent and updated reference.

Psoriatic arthritis added to coverage criteria in 8/2017.

Reauthorization duration updated to 12 months in 8/2020 (previously extended to 24 months earlier).

Not receiving in combination language updated to 'targeted immunomodulator' and examples updated in 7/2023.

3Covered Indications

12 monthsAuthorization Duration

Subcutaneous onlyFormulation Scope

Coverage Summary

UnitedHealthcare pharmacy prior authorization policy for subcutaneous Orencia (abatacept) covering initial authorization and reauthorization criteria for rheumatoid arthritis, polyarticular juvenile idiopathic arthritis (JIA), and psoriatic arthritis (PsA). The policy issues approvals for 12 months when criteria are met and includes a specific exclusion for concomitant use with other targeted immunomodulators. The intravenous formulation of abatacept is handled under the medical benefit (see coding/medical benefit reference).

This policy applies to the subcutaneous formulation only and establishes initial and reauthorization requirements (diagnosis-specific criteria and documentation of positive clinical response for reauthorization); the IV formulation is typically covered under the medical benefit and is referenced to the UnitedHealthcare Medical Benefit Drug Policy for Orencia.

Policy at-a-glance

Covered Indications3

Authorization Duration12 months

Formulation ScopeSubcutaneous only

Policy Number2025 P 1075-14

Effective Date2025-04-01

Last Review2025-01

Initial Therapy Criteria

Initial Authorization - Polyarticular Juvenile Idiopathic Arthritis (JIA)

Orencia will be approved based on both of the following criteria:

ALL of the following

Diagnosis of moderately to severely active rheumatoid arthritis
Patient is not receiving Orencia in combination with another targeted immunomodulator

ref": "b1_0

title": "Initial Authorization - Rheumatoid Arthritis"}

ref": "b1_1

Continuation / Reauthorization Criteria

Unproven / Concomitant Therapy Exclusions

Orencia (subcutaneous) must not be used in combination with another targeted immunomodulator. The policy requires that patients are not receiving Orencia together with other targeted immunomodulators as a condition of initial authorization and reauthorization.

The policy defines targeted immunomodulators to include both biologic DMARDs and targeted small molecules — examples listed in the policy include adalimumab, certolizumab (Cimzia), etanercept (Enbrel), baricitinib (Olumiant), golimumab (Simponi), upadacitinib (Rinvoq), tofacitinib (Xeljanz), secukinumab (Cosentyx), apremilast (Otezla), risankizumab (Skyrizi), ustekinumab (Stelara), ixekizumab (Taltz), guselkumab (Tremfya) and others shown in the policy examples.

Denial Risk

Concomitant targeted immunomodulator exclusion

Claims may be denied or authorization withheld if Orencia is used in combination with another targeted immunomodulator as listed in the policy examples.

Applicable Codes & Benefit Reference

Drug/MedicationNDCCovered

No codes listed

Medical benefit referencemixed

IV formulation

Intravenous abatacept typically covered under medical benefit — refer to UnitedHealthcare Medical Benefit Drug Policy for Orencia

Billing Rule

IV formulation billing

Intravenous abatacept is typically covered under the medical benefit; providers should bill under the medical benefit per UnitedHealthcare Medical Benefit Drug Policy for Orencia.

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization required for subcutaneous Orencia

Prior authorization is required for subcutaneous Orencia; initial and reauthorization approvals will be issued for 12 months when criteria are met.

Documentation Required

Reauthorization documentation

For reauthorization, provider must document positive clinical response to Orencia therapy.

Operational note: subcutaneous Orencia is covered under the pharmacy benefit and requires prior authorization per this pharmacy policy. The intravenous formulation of abatacept is typically covered under the medical benefit; providers should bill IV abatacept under the medical benefit per the UnitedHealthcare Medical Benefit Drug Policy for Orencia (see code/medical benefit reference).

Clinical Evidence & References

Orencia [package insert]. Bristol-Myers Squibb; May 2024.

Background

Orencia (abatacept) is a selective T-cell costimulation modulator indicated for adults with moderately to severely active rheumatoid arthritis, for patients 2 years of age and older with moderately to severely active polyarticular juvenile idiopathic arthritis (JIA), and for patients 2 years of age and older with active psoriatic arthritis (PsA). Concomitant use of Orencia with other immunosuppressives (for example, biologic DMARDs or JAK inhibitors) or targeted immunomodulators is not recommended.

Targeted immunomodulator: includes biologic DMARDs and targeted small molecules such as adalimumab, certolizumab, etanercept, baricitinib, golimumab, upadacitinib, tofacitinib, secukinumab, apremilast, risankizumab, ustekinumab, ixekizumab, guselkumab (examples listed in the policy).

Revision History

8/2017added

Psoriatic arthritis added to coverage criteria in 8/2017.

8/2020revised

Reauthorization duration updated to 12 months in 8/2020.

7/2023clarified

Not receiving in combination language updated to "targeted immunomodulator" and examples updated in 7/2023.