Orencia (abatacept intravenous infusion) — Cigna

Initial criteria

• Patient age ≥ 2 years; AND
• Orencia is being used for prevention of acute graft-versus-host disease; AND
• Patient will also receive a calcineurin inhibitor for prevention of acute graft-versus-host disease; AND
• Patient will also receive methotrexate for prevention of acute graft-versus-host disease; AND
• Patient will undergo hematopoietic stem cell transplantation from ONE of the following donors: matched unrelated donor OR 1-allele-mismatched unrelated donor; AND
• Medication is prescribed by or in consultation with an oncologist, hematologist, or physician affiliated with a transplant center

Approval duration

30 days (4 doses)