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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsWashington HCA Abatacept Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentWashington State Health Care AuthorityPolicy 66.27.00.AG-7

    Cytokine and CAM Antagonists: T-Lymphocyte Inhibitors — Abatacept (Orencia)

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    Washington Apple Health coverage and prior authorization for abatacept for polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and graft-versus-host disease.

    Policy Summary
    PayerWashington State Health Care Authority
    PolicyCytokine and CAM Antagonists: T-Lymphocyte Inhibitors — Abatacept (Orencia)
    Policy CodePolicy 66.27.00.AG-7
    Change TypeRemoved trial-of-preferred-products language
    Effective DateApr 1, 2026
    Next Review DateN/A
    Key ActionFor PJIA, psoriatic arthritis, or rheumatoid arthritis, document an ineffective trial of at least one non-Cytokine and CAM DMARD for a minimum of 3 months, unless contraindicated or not tolerated.
    SourceLink
    POLICY UPDATE CHANGES

    The current version removed trial-of-preferred-products language from the policy.

    4Covered clinical indications

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    6 months
    Standard initial authorization
    12 monthsStandard reauthorization
    J0129Covered HCPCS code
    No reauthorizationGVHD reauthorization

    Indication-Specific Coverage Criteria

    Polyarticular Juvenile Idiopathic Arthritis — Initial Therapy

    Covered when ALL of the following are met:

    PJIA initial therapy

    • Age and formulation: Patient meets the age limit for the requested product.Subcutaneous: age 2 years or older; intravenous: age 6 years or older
    • Clinical requirements: The prescriber is or has consulted a rheumatologist; the patient is not using another Cytokine and CAM medication; the diagnosis is PJIA; current weight is documented; and treatment with at least one non-Cytokine and CAM DMARD was ineffective unless all are contraindicated or not tolerated.Minimum DMARD trial: 3 months

      Examples include methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, and cyclosporine.

    Polyarticular Juvenile Idiopathic Arthritis — Reauthorization

    Covered when ALL of the following are met:

    PJIA reauthorization: The patient is not using another Cytokine and CAM medication and documentation demonstrates disease stability or a positive clinical response.12-month authorization

    Examples include improvement in joint pain, swelling, activities of daily living, or reduction in disease flares.

    Psoriatic Arthritis — Initial Therapy

    Covered when ALL of the following are met:

    Psoriatic arthritis initial therapy

    • Treatment or severity pathway: Treatment with at least one non-Cytokine and CAM DMARD was ineffective unless all are contraindicated or not tolerated; OR active, severe disease is documented with at least one specified severe-disease feature.Minimum DMARD trial: 3 months

      Severe-disease features include erosive disease; elevated CRP or ESR; long-term damage interfering with function; or major quality-of-life impairment due to high disease activity at many sites, including dactylitis or enthesitis, or functionally limiting arthritis at a few sites.

    Psoriatic Arthritis — Reauthorization

    Covered when ALL of the following are met:

    Psoriatic arthritis reauthorization: The patient is not using another Cytokine and CAM medication and documentation demonstrates disease stability or a positive clinical response.12-month authorization

    Examples include improvement in joint pain, swelling, activities of daily living, or reduction in disease flares.

    Rheumatoid Arthritis — Initial Therapy

    Covered when ALL of the following are met:

    Rheumatoid arthritis initial therapy: The patient is at least 18 years old; the prescriber is or has consulted a rheumatologist; the patient is not using another Cytokine and CAM medication; the diagnosis is RA; current weight is documented for intravenous formulation requests; baseline disease assessments are submitted; and treatment with at least one non-Cytokine and CAM DMARD was ineffective unless all are contraindicated or not tolerated.Minimum DMARD trial: 3 months

    Baseline assessments may include DAS28 with CRP, DAS28 with ESR, SDAI, CDAI, RAPID3, or PAS II.

    Rheumatoid Arthritis — Reauthorization

    Covered when ALL of the following are met:

    Rheumatoid arthritis reauthorization: The patient is not using another Cytokine and CAM medication and documentation demonstrates disease stability or a positive clinical response, including improvement in disease-activity measures when available.12-month authorization

    Disease-activity measures may include DAS28 with CRP or ESR, SDAI, CDAI, RAPID3, or PAS II scores.

    Graft-Versus-Host Disease — Initial Therapy

    Covered when ALL of the following are met:

    GVHD initial therapy

    • Transplant pathway: The patient has received an HSCT, abatacept is used as additional therapy with corticosteroids for chronic GVHD, and the patient has no response, such as steroid-refractory disease, to first-line therapy; OR the patient is undergoing HSCT from a matched or one-allele-mismatched unrelated donor, abatacept is used for acute GVHD prophylaxis with a calcineurin inhibitor and methotrexate, and antiviral prophylaxis for EBV reactivation will continue for 6 months after transplantation.

    Abatacept must not be used in combination with another Cytokine and CAM medication. This restriction applies to coverage for PJIA, PsA, RA, and GVHD.

    GVHD reauthorization is not permitted under this policy. Coverage for GVHD is limited to the applicable initial-therapy criteria and a 6-month authorization period when those criteria are met.

    Coding and Authorization Parameters

    Covered HCPCS CodeHCPCSCovered
    J0129Injection, abatacept, 10 mg
    Non-Cytokine and CAM DMARD Trial
    Required conditionsFor PJIA, psoriatic arthritis, or rheumatoid arthritis, at least one non-Cytokine and CAM DMARD must have been ineffective.
    Minimum durationThe required DMARD trial is a minimum of 3 months.
    ExceptionThe trial requirement does not apply when all applicable DMARDs are contraindicated or not tolerated.
    Authorization Duration
    Initial authorization6 months when applicable initial-therapy criteria are met.
    PJIA, PsA, and RA reauthorization12 months when disease stability or a positive clinical response is documented.

    Provider Requirements and Decision Risks

    Prior Authorization

    Preferred Drug List and Prior Authorization

    New-to-market drugs in this class are non-preferred on the Apple Health Preferred Drug List (AHPDL) and require prior authorization. Non-preferred agents generally require an inadequate response or documented intolerance due to severe adverse reaction or contraindication to at least two preferred agents; when only one preferred agent is available, document inadequate response to that agent.

    • Check the current AHPDL for preferred products: https://www.hca.wa.gov/assets/billers-and-providers/applehealth-preferred-drug-list.xlsx
    • If a drug receives a new FDA-approved indication, medical necessity for that indication is determined case by case following FDA labeling.
    Note

    Medical Necessity Review

    Abatacept (Orencia) may be medically necessary when the applicable clinical-policy criteria are met. If all criteria are not met, the clinical reviewer may determine that a medically necessary need exists and approve the request on a case-by-case basis; the reviewer may also use reauthorization criteria for a patient previously established on therapy who is new to Apple Health.

    Abatacept Overview

    Abatacept (Orencia) is a biologic disease-modifying antirheumatic drug and T-lymphocyte inhibitor used for inflammatory rheumatologic diseases, including polyarticular juvenile idiopathic arthritis, psoriatic arthritis, and rheumatoid arthritis. Intravenous abatacept is also covered in selected graft-versus-host disease settings, including chronic GVHD treatment after hematopoietic stem cell transplantation and acute GVHD prophylaxis around specified transplants.

    Clinical Definitions

    Polyarticular Juvenile Idiopathic Arthritis (PJIA)
    Disease categoryPJIA is a subset of juvenile idiopathic arthritis.
    Joint involvementPJIA is defined by arthritis in five or more joints.
    TimingThe five-or-more-joint involvement occurs during the first six months of illness.
    Graft-Versus-Host Disease (GVHD)
    Transplant associationGVHD is a complication associated with hematopoietic stem cell transplantation.
    Chronic GVHD contextThe policy addresses chronic GVHD treatment after hematopoietic stem cell transplantation, including additional therapy with corticosteroids when first-line therapy has not produced a response.

    Initial Authorization Pathways

    PJIA Initial Authorization

    Initial therapy for PJIA requires ALL of the following:

    PJIA initial authorization: Abatacept is requested for PJIA; the patient meets the applicable age limit; the prescriber is or has consulted a rheumatologist; the patient is not using another Cytokine and CAM medication; current weight is documented; and treatment with at least one non-Cytokine and CAM DMARD was ineffective unless all are contraindicated or not tolerated.Subcutaneous: age 2 years or older; intravenous: age 6 years or older; minimum DMARD trial: 3 months

    Examples of qualifying DMARDs include methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, and cyclosporine.

    PsA Initial Authorization

    Initial therapy for PsA requires ALL of the following, including ONE treatment or severity pathway:

    PsA initial authorization

    Reauthorization Requirements

    Reauthorization

    Continuation therapy is covered when ALL applicable criteria are met:

    PJIA, PsA, or RA continuation: The patient is not using another Cytokine and CAM medication and documentation demonstrates disease stability or a positive clinical response.12-month authorization

    Examples include improvement in joint pain, swelling, activities of daily living, reduction in disease flares, or improvement in disease-activity measures such as DAS28 with CRP or ESR, SDAI, CDAI, RAPID3, or PAS II. GVHD reauthorization is not permitted under this policy.

    Required Prior Therapy

    StepApplicable indicationsRequirementDurationException or alternative
    1Polyarticular juvenile idiopathic arthritis (PJIA), psoriatic arthritis (PsA), or rheumatoid arthritis (RA)Trial at least one non-Cytokine and CAM disease-modifying antirheumatic drug (DMARD) that was ineffectiveMinimum 3 monthsThe trial is not required when all applicable DMARDs are contraindicated or not tolerated. For PsA, active severe disease with at least one specified severe-disease feature may qualify instead, including erosive disease, elevated CRP or ESR, function-interfering long-term damage, or major quality-of-life impairment from high disease activity or functionally limiting arthritis.

    Orencia Dosing and Quantity Limits

    Orencia — Subcutaneous Dosing
    FormulationSubcutaneous Orencia is available as an auto-injector or prefilled syringe.
    Dose125 mg once weekly.
    Quantity limit4 pens or prefilled syringes per 28-day supply.
    Orencia — Intravenous Dosing
    FormulationIntravenous Orencia is supplied as a 250 mg/15 mL vial.
    Loading scheduleUp to 1,000 mg at weeks 0, 2, and 4.
    Maintenance scheduleThen every 4 weeks thereafter.

    GVHD Administration Setting

    Billing Rule

    Administer GVHD treatment in the transplant setting

    For GVHD, use the intravenous formulation only, with dosing intended for the transplant hospital outpatient setting. Accurate dosing is intended to be achieved intravenously in the transplant setting.

    Policy Summary
    PayerWashington State Health Care Authority
    PolicyCytokine and CAM Antagonists: T-Lymphocyte Inhibitors — Abatacept (Orencia)
    Policy CodePolicy 66.27.00.AG-7
    Change TypeRemoved trial-of-preferred-products language
    Effective DateApr 1, 2026
    Next Review DateN/A
    Key ActionFor PJIA, psoriatic arthritis, or rheumatoid arthritis, document an ineffective trial of at least one non-Cytokine and CAM DMARD for a minimum of 3 months, unless contraindicated or not tolerated.
    SourceLink
    On This Page
    Indication-Specific Coverage CriteriaCoding and Authorization ParametersProvider Requirements and Decision RisksAbatacept OverviewClinical DefinitionsInitial Authorization PathwaysReauthorization RequirementsRequired Prior TherapyOrencia Dosing and Quantity LimitsGVHD Administration Setting
    GVHD reauthorizationAbatacept may not be reauthorized for graft-versus-host disease under this policy.
    Step Therapy

    Non-Cytokine and CAM DMARD Trial

    For PJIA and RA, document that treatment with at least one non-Cytokine and CAM DMARD was ineffective, unless all such options are contraindicated or not tolerated. The minimum trial is 3 months; PsA may meet this requirement through the DMARD trial or through the specified active, severe disease pathway.

    • Examples include methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine, and other applicable non-Cytokine and CAM DMARDs.
    • For PsA, the alternative requires provider-documented active, severe disease plus at least one of: erosive disease; elevated CRP or ESR; long-term function-interfering damage; or major quality-of-life impairment from high disease activity or functionally limiting arthritis.
    Documentation Required

    Required Clinical Documentation

    Submit complete clinical documentation with each request, including the diagnosis, patient age, prescriber or consulting specialist, requested formulation, and required treatment history. Provide current weight when required by the product and indication.

    • PJIA: age at least 2 years for subcutaneous or at least 6 years for intravenous abatacept; rheumatologist involvement; diagnosis and current weight.
    • PsA: age at least 2 years; rheumatologist or dermatologist involvement; diagnosis; current weight for pediatric and intravenous requests.
    • RA: age at least 18 years; rheumatologist involvement; diagnosis; current weight for intravenous requests; baseline disease activity assessment.
    • GVHD: age at least 2 years; oncologist or hematologist involvement; intravenous formulation; current weight; and transplant, prophylaxis, or treatment details as applicable.
    Documentation Required

    Reauthorization Response Documentation

    For PJIA, PsA, and RA reauthorization, document that abatacept is not being used with another Cytokine and CAM medication and submit evidence of disease stability or positive clinical response. Examples include improvement in joint pain or swelling, activities of daily living, disease flares, or validated disease-activity scores.

    • PJIA and PsA reauthorization is generally for 12 months when criteria are met.
    • RA response documentation may include improvement in DAS28 with CRP or ESR, SDAI, CDAI, RAPID3, or PAS II scores.
    • GVHD abatacept may not be reauthorized under the policy.
    Documentation Required

    RA Baseline Assessment

    For initial RA requests, include an accepted baseline disease-activity assessment before treatment. This establishes the clinical baseline against which response can be evaluated at reauthorization.

    • Acceptable examples include DAS28 with CRP, DAS28 with ESR, SDAI, CDAI, RAPID3, or PAS II.
    Documentation Required

    GVHD Transplant Documentation

    For GVHD requests, document the patient’s hematopoietic stem cell transplant (HSCT) status and the applicable treatment pathway. Include prior or planned therapies, steroid-refractory or no-response disease details when applicable, and all prophylaxis requirements.

    • Post-HSCT chronic GVHD: document use with corticosteroids and no response, such as steroid-refractory disease, to first-line therapy options.
    • Planned HSCT: document transplant from a matched or one-allele-mismatched unrelated donor, use for acute GVHD prophylaxis with a calcineurin inhibitor and methotrexate, and antiviral prophylaxis for EBV reactivation continuing for 6 months after transplantation.
    • GVHD requests require intravenous abatacept; the policy does not cover the subcutaneous formulation for this indication.
    Denial Risk

    Failure to Meet Clinical Criteria

    Requests may be denied when required clinical criteria are not documented or are not met. Review age, diagnosis, prescriber specialty, formulation, weight, disease severity, required prior treatment, baseline assessment, and other indication-specific requirements before submission.

    • PJIA: subcutaneous requests require age 2 or older; intravenous requests require age 6 or older.
    • PsA: requires age 2 or older and rheumatologist or dermatologist involvement, plus the required DMARD trial or severe-disease pathway.
    • RA: requires age 18 or older, rheumatologist involvement, baseline assessment, and the required DMARD trial.
    • GVHD: requires age 2 or older, oncologist or hematologist involvement, intravenous formulation, current weight, and qualifying HSCT or prophylaxis documentation.
    • Failure to establish the covered diagnosis, required severity or response, formulation, weight, specialist involvement, or other applicable criterion may result in denial.
    Denial Risk

    Concurrent Cytokine and CAM Therapy

    Do not use abatacept with another Cytokine and CAM medication. Concurrent therapy is prohibited for initial and reauthorization requests across PJIA, PsA, RA, and GVHD.

    • Document that no other Cytokine and CAM medication is being used in combination with abatacept.
    Denial Risk

    GVHD Formulation Requirement

    For GVHD, only intravenous abatacept is covered under this policy. Subcutaneous abatacept is not covered for the GVHD indication.

    • The request must document the intravenous formulation and the applicable HSCT, chronic GVHD, or acute GVHD prophylaxis criteria.
    Acute GVHD contextThe policy also addresses acute GVHD prophylaxis around transplantation from a matched or one-allele-mismatched unrelated donor.
    Treatment or severe-disease pathway:
    Treatment with at least one non-Cytokine and CAM DMARD was ineffective unless all are contraindicated or not tolerated; OR active, severe disease is documented with at least one of the following: erosive disease; elevated CRP or ESR; long-term damage interfering with function, such as joint deformities or vision loss; or major quality-of-life impairment due to high disease activity at many sites, including dactylitis or enthesitis, or functionally limiting arthritis at a few sites.
    Minimum DMARD trial: 3 months when the treatment pathway is used

    RA Initial Authorization

    Initial therapy for RA requires ALL of the following:

    RA initial authorization: The patient is at least 18 years old; the prescriber is or has consulted a rheumatologist; the patient is not using another Cytokine and CAM medication; the diagnosis is RA; current weight is documented for intravenous formulation requests; baseline disease assessments are submitted; and treatment with at least one non-Cytokine and CAM DMARD was ineffective unless all are contraindicated or not tolerated.Minimum DMARD trial: 3 months

    Baseline assessments may include DAS28 with CRP, DAS28 with ESR, SDAI, CDAI, RAPID3, or PAS II.

    GVHD Initial Authorization

    Initial therapy for GVHD requires ALL of the following and ONE transplant pathway:

    GVHD initial authorization

    • Transplant pathway: The patient has received an HSCT, abatacept is used as additional therapy with corticosteroids for chronic GVHD, and the patient has no response, such as steroid-refractory disease, to first-line therapy; OR the patient is undergoing HSCT from a matched or one-allele-mismatched unrelated donor, abatacept is used for acute GVHD prophylaxis with a calcineurin inhibitor and methotrexate, and antiviral prophylaxis for EBV reactivation will continue for 6 months after transplantation.
    Orencia — GVHD Transplant Dosing
    FormulationUse intravenous Orencia for the GVHD transplant regimen.
    Dose and timing10 mg/kg IV on day -1 before transplant and on post-transplant days 5, 14, and 28.
    Per-dose maximumUp to 1,000 mg per dose.