Orencia — CareFirst (Caremark)

Initial criteria

• Requested medication is used for chronic graft versus host disease
• Member achieves or maintains a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition
• Member has documented negative tuberculosis (TB) test (TST or IGRA) within 6 months of initiating therapy for biologic-naive members
• If TB test positive, further testing confirms no active disease; latent TB must be treated before initiation
• Requested medication not used concomitantly with other biologic drugs or targeted synthetic drugs for the same indication

Reauthorization criteria

• Member continues to achieve or maintain a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of chronic graft versus host disease

Approval duration

12 months