Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Preferred Agents:
Polyarticular Juvenile Idiopathic Arthritis (PJIA)
TNF Inhibitors
adalimumab-adaz
adalimumab-adbm - labeler 00597
CYLTEZO (adalimumab-abdm)
ENBREL (etanercept)
HUMIRA (adalimumab)
SIMLANDI (adalimumab-ryvk)
YUSIMRY (adalimumab-aqvh)
T-cell Costimulation Blocker
ORENCIA (abatacept) - 125 mg/mL syringe subcutaneous
Psoriatic Arthritis (PsA)
T-cell Costimulation Blocker
ORENCIA (abatacept) - 125 mg/mL syringe subcutaneous
Rheumatoid Arthritis (RA)
TNF Inhibitors
adalimumab-adaz
adalimumab-adbm - labeler 00597
AVSOLA (infliximab-axxq)
CYLTEZO (adalimumab-abdm)
ENBREL (etanercept)
HUMIRA (adalimumab)
RENFLEXIS (infliximab-abda)
SIMLANDI (adalimumab-ryvk)
SIMPONI (golimumab) subcutaneous
YUSIMRY (adalimumab-aqvh)
T-cell Costimulation Blocker
ORENCIA (abatacept) - 125 mg/mL syringe subcutaneous
Initial Criteria
The use of abatacept (Orencia) IV may be considered medically necessary when
ALL
of the following criteria are met:
-
The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route);
and
-
Abatacept (Orencia) IV must be prescribed by, or in consult with, a specialist in the area of the individual's treated diagnosis;
and
- The individual must have had a three (3)-month trial of a preferred agent from each class approved for patient's diagnosis, as evidenced by paid claims or pharmacy printouts: and,
- Clinical justification must be provided why a self-administered agent cannot be used (subject to clinical review).
Reauthorization Criteria
The continues use of abatacept (Orencia) IV may be considered medically necessary when
ALL
of the following criteria are met:
-
The individual has previously been approved for abatacept (Orencia) through Blue Cross Blue Shield of North Dakota's precertification process;
and
-
The prescriber has provided documentation that the individual has demonstrated disease stability or beneficial response to therapy;
and
- The individual must continue to meet applicable initial criteria.
The use of abatacept (Orencia) IV for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
