CurrentUnitedHealthcarePolicy N/A

Orencia (abatacept) subcutaneous prior authorization

Prior authorization and reauthorization criteria for the subcutaneous formulation of abatacept (Orencia) for RA, polyarticular JIA, and psoriatic arthritis; applies to UnitedHealthcare pharmacy benefit and providers requesting coverage.

Policy Summary

PayerUnitedHealthcare

PolicyOrencia (abatacept) subcutaneous prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization showing diagnosis and that the patient is not receiving another systemic targeted immunomodulator for the same condition.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

subcutaneousformulation

RA, JIA, PsAindications

no concomitant targeted immunomodulatorcoverage restriction

Coverage Criteria for Orencia (abatacept) Subcutaneous

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Initial Therapy - Rheumatoid Arthritis

Covered for moderately to severely active rheumatoid arthritis when ALL of the following are met:

ALL of the following

Diagnosis of moderately to severely active rheumatoid arthritis
Concomitant therapy: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition
Examples include adalimumab, Cimzia (certolizumab), Enbrel (etanercept), Olumiant (baricitinib), Simponi (golimumab), Rinvoq (upadacitinib), Xeljanz (tofacitinib)

Authorization duration: Authorization will be issued for 12 months

Reauthorization - Rheumatoid Arthritis

Reauthorization for rheumatoid arthritis when ALL of the following are met:

ALL of the following

Clinical response: Documentation of positive clinical response to Orencia therapy
Concomitant therapy: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition
Examples include adalimumab, Cimzia (certolizumab), Enbrel (etanercept), Olumiant (baricitinib), Simponi (golimumab), Rinvoq (upadacitinib), Xeljanz (tofacitinib)

Authorization duration: Authorization will be issued for 12 months

Initial Therapy - Polyarticular JIA

Covered for moderately to severely active polyarticular juvenile idiopathic arthritis when ALL of the following are met:

ALL of the following

Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis
Concomitant therapy: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition
Examples include adalimumab, Cimzia (certolizumab), Enbrel (etanercept), Olumiant (baricitinib), Simponi (golimumab), Rinvoq (upadacitinib), Xeljanz (tofacitinib)

Authorization duration: Authorization will be issued for 12 months

Reauthorization - Polyarticular JIA

Reauthorization for polyarticular JIA when ALL of the following are met:

ALL of the following

Clinical response: Documentation of positive clinical response to Orencia therapy
Concomitant therapy: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition
Examples include adalimumab, Cimzia (certolizumab), Enbrel (etanercept), Olumiant (baricitinib), Simponi (golimumab), Rinvoq (upadacitinib), Xeljanz (tofacitinib)

Authorization duration: Authorization will be issued for 12 months

Initial Therapy - Psoriatic Arthritis

Covered for active psoriatic arthritis when ALL of the following are met:

ALL of the following

Diagnosis of active psoriatic arthritis
Concomitant therapy: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition
Examples include adalimumab, Cimzia (certolizumab), Cosentyx (secukinumab), Enbrel (etanercept), Olumiant (baricitinib), Otezla (apremilast), Rinvoq (upadacitinib), Simponi (golimumab), Skyrizi (risankizumab), Stelara (ustekinumab), Taltz (ixekizumab), Tremfya (guselkumab), Xeljanz (tofacitinib)

Authorization duration: Authorization will be issued for 12 months

Reauthorization - Psoriatic Arthritis

Reauthorization for psoriatic arthritis when ALL of the following are met:

ALL of the following

Clinical response: Documentation of positive clinical response to Orencia therapy
Concomitant therapy: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition
Examples include adalimumab, Cimzia (certolizumab), Cosentyx (secukinumab), Enbrel (etanercept), Olumiant (baricitinib), Otezla (apremilast), Rinvoq (upadacitinib), Simponi (golimumab), Skyrizi (risankizumab), Stelara (ustekinumab), Taltz (ixekizumab), Tremfya (guselkumab), Xeljanz (tofacitinib)

Authorization duration: Authorization will be issued for 12 months

Initial Therapy Requirements

Initial Therapy

Initial authorization requires diagnosis-specific criteria and no concomitant targeted immunomodulator therapy for the same condition.

ALL of the following

Diagnosis RA: Diagnosis of moderately to severely active rheumatoid arthritis
No concomitant targeted immunomodulator: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition

ALL of the following

Diagnosis JIA: Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis
No concomitant targeted immunomodulator: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition

ALL of the following

Diagnosis PsA: Diagnosis of active psoriatic arthritis
No concomitant targeted immunomodulator: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition
Examples listed in policy

Authorization duration: Authorization will be issued for 12 months

Reauthorization / Continuation Criteria

Reauthorization

Reauthorization requires the following:

ALL of the following

Clinical response: Documentation of positive clinical response to Orencia therapy
Concomitant therapy: Patient is not receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition

Authorization duration: Authorization will be issued for 12 months

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for subcutaneous Orencia; initial approval requires a covered diagnosis. Authorization will be issued for 12 months.

Initial authorization examples include: moderately to severely active rheumatoid arthritis; moderately to severely active polyarticular juvenile idiopathic arthritis; active psoriatic arthritis.

Step Therapy

Supply limits / Step therapy

Supply limits, medical necessity, and/or step therapy may apply per plan. The intravenous infusion is typically covered under the medical benefit; refer to the UnitedHealthcare Medical Benefit Drug Policy for Orencia for billing/benefit routing.

Documentation Required

Reauthorization — Clinical Response Required

For reauthorization, documentation of positive clinical response to Orencia therapy is required. Authorization for reauthorization will be issued for 12 months.

Denial Risk

Concomitant Targeted Immunomodulator — Denial Risk

Coverage will be denied if the patient is receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition (examples: adalimumab, certolizumab, etanercept, baricitinib, golimumab, upadacitinib, tofacitinib, and others listed per indication).

Definitions

Concomitant systemic targeted immunomodulator — definition

DefinitionOther biologic disease-modifying antirheumatic drugs (bDMARDs) or targeted synthetic agents; examples listed in policy include adalimumab, certolizumab (Cimzia), etanercept, baricitinib, golimumab, upadacitinib, tofacitinib, secukinumab, apremilast, risankizumab, ustekinumab, ixekizumab, guselkumab.

Clinical guidanceConcomitant use of Orencia (abatacept) with other immunosuppressives (e.g., bDMARDs, JAK inhibitors) is not recommended.

Policy effectCoverage will be denied if the patient is receiving Orencia in combination with another systemic targeted immunomodulator for treatment of the same condition.

ScopeTerm applies to systemic targeted immunomodulators used for the same indication (RA, polyarticular JIA, PsA) as described in this policy.

Examples noteThe policy provides specific example agents but is not limited to those listed; providers should assume other bDMARDs and targeted synthetic agents fall under this definition.

Background

Abatacept (Orencia) is a selective T‑cell costimulation modulator indicated for treatment of adults with moderately to severely active rheumatoid arthritis, patients 2 years and older with moderately to severely active polyarticular juvenile idiopathic arthritis, and patients 2 years and older with active psoriatic arthritis. The mechanism targets T‑cell activation to reduce the immune-mediated joint inflammation underlying these conditions.

Step Therapy / Supply Limits

Rule	Details
Supply limits	Supply limits may be applied per plan and clinical rules; quantity or refill limits could restrict dispensing of the subcutaneous formulation.
Medical necessity	Coverage is subject to medical necessity determinations consistent with the plan; medical necessity requirements may be applied prior to approval or refills.
Step therapy	Step therapy may be required by the plan as a condition of coverage for the subcutaneous formulation of Orencia.

Site of Care Notes

Billing Rule

IV formulation billed to medical benefit; pharmacy policy covers subcutaneous

The intravenous (infusion) formulation of abatacept (Orencia) is typically covered under the medical benefit; this pharmacy policy applies to the subcutaneous product.

Refer to the UnitedHealthcare Medical Benefit Drug Policy for Orencia (intravenous) for coverage and billing under the medical benefit.

Policy Summary

PayerUnitedHealthcare

PolicyOrencia (abatacept) subcutaneous prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization showing diagnosis and that the patient is not receiving another systemic targeted immunomodulator for the same condition.

SourceLink

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