Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Preferred Agents:
Polyarticular Juvenile Idiopathic Arthritis (PJIA)
Janus Kinase (JAK) Inhibitors
XELJANZ (tofacitinib)
XELJANZ (tofacitinib) ORAL SOLUTION
XELJANZ XR (tofacitinib)
Psoriatic Arthritis (PsA)
Anti-TNF Inhibitors
ENBREL (etanercept)
HUMIRA (adalimumab)
Phosphodiesterase 4 (PDE4) Inhibitor
OTEZLA (apremilast)
Janus Kinase (JAK) Inhibitors
XELJANZ (tofacitinib)
Rheumatoid Arthritis (RA)
Anti-TNF Inhibitors
ENBREL (etanercept)
HUMIRA (adalimumab)
Janus Kinase (JAK) Inhibitors
XELJANZ (tofacitinib)
Anti-Interleukin-1 (IL-1) Receptor Inhibitors
KINERET (anakinra)
The use of abatacept (Orencia) may be considered medically necessary when ALL of the following criteria are met:
- The member must have an FDA-approved indication for use (meets label recommendations for diagnosis and age); and
- The member must have had a 3-month trial of a preferred agent from each class approved for patient’s diagnosis, as
evidenced by paid claims or pharmacy printouts.
Abatacept (Orencia) IV for any other indication is considered experimental/investigational and therefore non-covered. Scientific evidence has not established the effectiveness for any other indication.
Procedure Codes
