ADULT RHEUMATOID ARTHRITIS (RA)
Abatacept (Orencia®) is considered medically necessary and, therefore, covered when used to reduce signs and symptoms, induce major clinical response, inhibit the progression of structural damage, and improve physical function in individuals who have moderately to severely active RA when all of the following inclusion criteria are met:
- The individual has had an inadequate response after at least three months to one or more disease-modifying antirheumatic drugs (DMARDs) or tumor necrosis factor (TNF)-antagonists, or the use of all DMARDs or TNF-antagonists is contraindicated in the individual.
- The drug is prescribed by a rheumatologist.
- The individual is 18 years of age or older.
POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS
Abatacept (Orencia®) is considered medically necessary and, therefore, covered when used to reduce signs and symptoms in individuals who have moderately to severely active polyarticular juvenile idiopathic arthritis. Abatacept (Orencia®) may be used as monotherapy or concomitantly with methotrexate when all of the following inclusion criteria are met:
- The individual has had an inadequate response after at least three months to one or more DMARDs or TNF-antagonists, or the use of all DMARDs or TNF-antagonists is contraindicated in the individual.
- The drug is prescribed by a rheumatologist.
- The individual is 6 years of age or older.
All other uses for abatacept (Orencia®) are considered experimental/investigational and, therefore, not covered unless the indication is supported as an accepted off-label use, as defined in the Company medical policy on off-label coverage for prescription drugs and biologics. Uses of abatacept (Orencia®) that are not supported in either this medical policy or the off-label coverage policy are considered experimental/investigational and, therefore, not covered.
The use of abatacept (Orencia®) with other TNF-antagonists (eg, adalimumab [Humira®], etanercept [Enbrel®], infliximab [Remicade®]) or interleukin-1 (IL-1) inhibitors (eg, anakinra [Kineret®]) is considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of these regimens cannot be established by a review of the available published peer-reviewed literature.
PRECERTIFICATION OR PREAPPROVAL REQUIREMENTS
For most of the Company's products, abatacept (Orencia®) requires precertification or preapproval, regardless of place of service. Individual product requirements must be verified.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
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