Orencia intravenous — Medica

Psoriatic Arthritis

Initial criteria

Patient meets the standard Inflammatory Conditions – Orencia Subcutaneous Prior Authorization Policy criteria
AND meets ONE of the following:
a) Rheumatoid Arthritis – patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR [documentation required]
b) Juvenile Idiopathic Arthritis – patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq/Rinvoq LQ, or Xeljanz tablets or oral solution [documentation required]
c) Psoriatic Arthritis, age ≥ 18 years – patient has tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, Stelara subcutaneous, Taltz, Tremfya subcutaneous, or Xeljanz/XR [documentation required]
d) Psoriatic Arthritis, age < 18 years – patient has tried ONE of Enbrel, Rinvoq/Rinvoq LQ, or Stelara subcutaneous [documentation required]
e) patient has been established on Orencia intravenous for at least 90 days
f) patient has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, OR a demyelinating disorder
g) patient has been established on Orencia subcutaneous for at least 90 days with prescription claims history confirming a ≥90‑day supply within past 130 days, or verified by prescriber if claims history unavailable

1 year