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The Policy VaultThe Policy Vault

Orencia SC — Medica

ankylosing spondylitis

Preferred products

  • adalimumab-adbm
  • adalimumab-adaz
  • Simlandi/adalimumab-ryvk
  • Enbrel
  • Cimzia
  • Taltz
  • Otezla
  • Skyrizi SC
  • ustekinumab SC products (Imuldosa SC, Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC)
  • Tremfya SC

Initial criteria

  • Patient meets the respective standard Prior Authorization Policy criteria for the requested indication.
  • Trial of the Preferred Product(s) according to the table for the specific indication is required prior to approval of a Non-Preferred Product when clinically appropriate.
  • Step 1: Trial of Preferred Products (adalimumab products adalimumab-adbm, adalimumab-adaz, Simlandi/adalimumab-ryvk, Enbrel, Taltz, Otezla, Skyrizi SC, ustekinumab SC products Imuldosa SC, Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC, Tremfya SC, Cimzia) depending on indication.
  • Step 2a: If inadequate response or not appropriate, trial of the corresponding Step 2a Non-Preferred Product directed to one Step 1 product (e.g., tocilizumab SC such as Actemra SC or Tyenne SC directed to adalimumab; or Rinvoq/Rinvoq LQ/Xeljanz/Xeljanz XR/Xeljanz oral solution directed to Enbrel or adalimumab).
  • Step 2b: If inadequate response or not appropriate, trial of Step 2b Non-Preferred Product (Bimzelx) directed to one Step 1 product.
  • Step 3a: If inadequate response or not appropriate, trial of Step 3a Non-Preferred Products (Cimzia, Kevzara, Kineret, Orencia SC, Olumiant, Simponi SC, Cosentyx SC) directed to two Step 1 or 2a Products, with documentation required.
  • Documentation required for trials of Preferred Products (chart notes, prescription claims, or receipts).

Reauthorization criteria

  • Patient must demonstrate continuation of therapy verified via prescription claims history or prescriber attestation.
  • If ≥130 days of claims history available, patient must have received the Non-Preferred Product for 90 to 120 days within a 130-day look-back period; or if not available, prescriber must verify treatment for 90 to 120 days with paid claims.
  • Continuation approval subject to standard PA criteria and conditions as noted.

Approval duration

1 year