Orencia (abatacept) — United Healthcare
Rheumatoid Arthritis
Preferred products
- preferred adalimumab products
- Cimzia (certolizumab)
- Enbrel (etanercept)
- Rinvoq (upadacitinib)
- Simponi (golimumab)
- Xeljanz/Xeljanz XR (tofacitinib)
Initial criteria
- Diagnosis of moderately to severely active rheumatoid arthritis
- AND One of the following:
- a) Both of the following:
- i. One of the following:
- • History of failure to a 3 month trial of one non-biologic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine) at maximally indicated doses unless contraindicated or with clinically significant adverse effects (document drug, date, and duration of trial)
- OR • Patient has been previously treated with a targeted immunomodulator FDA-approved for rheumatoid arthritis (documented by claims history or medical records) [e.g., Cimzia, adalimumab, Simponi, Olumiant, Rinvoq, Xeljanz/Xeljanz XR, Enbrel]
- AND ii. History of failure, contraindication, or intolerance to two of the following preferred products (document drug, date, and duration of trial)
- • One of the preferred adalimumab products
- • Cimzia (certolizumab)
- • Enbrel (etanercept)
- • Rinvoq (upadacitinib)
- • Simponi (golimumab)
- • Xeljanz/Xeljanz XR (tofacitinib)
- OR b) Both of the following:
- i. Patient is currently on Orencia therapy as documented by claims history or submission of medical records (document date and duration of therapy)
- AND ii. Patient has not received a manufacturer supplied sample or Orencia Co-Pay Program assistance as means to establish as a current user
- AND Patient is not receiving Orencia in combination with another targeted immunomodulator [e.g., Enbrel, Cimzia, Simponi, adalimumab, Xeljanz, Olumiant, Rinvoq]
- AND Prescribed by or in consultation with a rheumatologist
Reauthorization criteria
- Documentation of positive clinical response to Orencia therapy
- AND Patient is not receiving Orencia in combination with another targeted immunomodulator [e.g., Enbrel, Cimzia, Simponi, adalimumab, Xeljanz, Olumiant, Rinvoq]
Approval duration
12 months