Orencia subcutaneous — Medica

Rheumatoid Arthritis

Preferred products

Meets the standard Inflammatory Conditions – Orencia Subcutaneous Prior Authorization Policy criteria
AND for Rheumatoid Arthritis: patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR [documentation required]
OR for 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]
OR for Psoriatic Arthritis (age ≥ 18 years): patient has tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya subcutaneous, or Xeljanz/XR [documentation required]
OR for Psoriatic Arthritis (age < 18 years): patient has tried ONE of Enbrel, Otezla, Rinvoq/Rinvoq LQ, or an ustekinumab subcutaneous product [documentation required]
OR patient has been established on Orencia intravenous for at least 90 days OR has heart failure, a previously treated lymphoproliferative disorder, a previous serious infection, or a demyelinating disorder
OR patient has been established on Orencia subcutaneous for ≥ 90 days with verification in prescription claims history or by prescriber if claims unavailable

Meets the standard Inflammatory Conditions – Orencia Subcutaneous Prior Authorization Policy criteria
AND continues to meet one of the same criteria used for initial approval (experience or tolerability, comorbidity, or prescriber verification as described)

1 year