J0129, Injection, abatacept, 10 mg (code may be used for medicare when drug
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- For continuation of therapy: Documentation of positive clinical response (explicitly required for PJIA, RA, PsA, chronic GVHD continuation criteria).
- For rheumatoid arthritis initial therapy: documentation of history of failure or intolerance to a 3-month trial of one non-biologic DMARD at maximally indicated doses unless contraindicated or clinically significant adverse effects are experienced; OR documentation of prior treatment with a targeted immunomodulator FDA-approved for rheumatoid arthritis; OR documentation the patient is currently on Orencia.
- For psoriatic arthritis initial therapy: documentation of history of failure to a 3-month trial of methotrexate at the maximally indicated dose unless contraindicated or clinically significant adverse effects are experienced; OR documentation of prior treatment with a targeted immunomodulator FDA-approved for the treatment of psoriatic arthritis; OR documentation the patient is currently on Orencia.
- For polyarticular juvenile idiopathic arthritis: documentation of diagnosis of moderately to severely active PJIA, that Orencia is initiated and titrated according to FDA labeled dosing for PJIA, and that the patient is not receiving Orencia in combination with a targeted immunomodulator; prescribed by or in consultation with a rheumatologist for the 'medically necessary' pathway.
- For chronic GVHD: documentation of diagnosis of steroid-refractory chronic GVHD; documentation that patient is receiving Orencia in combination with systemic corticosteroids OR is intolerant to systemic corticosteroid therapy; documentation of positive clinical response for continuation; documentation that patient continues to experience chronic GVHD (or has been successfully tapered off corticosteroids).
- For prophylaxis of aGVHD: documentation patient is at least 2 years old; documentation patient is undergoing HSCT from a matched donor or a 1 allele-mismatched unrelated donor; documentation patient is receiving Orencia in combination with a calcineurin inhibitor and methotrexate; dosing/administration dates consistent with Day -1, Days 5, 14, and 28 as per clinical trial (if applicable).
Key Coverage Criteria
- Orencia is proven for the treatment of polyarticular juvenile idiopathic arthritis when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis (PJIA); and Orencia is initiated and titrated according to U.S. [...]
- Orencia is medically necessary for the treatment of polyarticular juvenile idiopathic arthritis when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis (PJIA); Orencia is initiated and titrated according to U.S. [...]
- Orencia is proven for the treatment of rheumatoid arthritis when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of moderately to severely active rheumatoid arthritis (RA); Orencia is initiated and titrated according to FDA labeled dosing for rheumatoid arthritis; Patient is not receiving Orencia in combination with a targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), adalimumab, Xeljanz (tofacitinib), Olum [...]
- Orencia is medically necessary for the treatment of rheumatoid arthritis when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of moderately to severely active rheumatoid arthritis (RA); One of the following: History of failure intolerance to a 3-month trial of one non-biologic disease modifying anti-rheumatic drug (DMARD) [e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine] at maximally indicated doses unless contraindicated or clinical [...]
- Orencia is proven for the treatment of psoriatic arthritis when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of active psoriatic arthritis (PsA); Orencia is initiated and titrated according to FDA labeled dosing for psoriatic arthritis; Patient is not receiving Orencia in combination with a targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), adalimumab, ustekinumab, Skyrizi (risankizumab), Tremfya (guselk [...]
- Orencia is medically necessary for the treatment of psoriatic arthritis when all of the following criteria are met: For initial therapy, all of the following: Diagnosis of active psoriatic arthritis (PsA); One of the following: History of failure to a 3-month trial of methotrexate at the maximally indicated dose, unless contraindicated or clinically significant adverse effects are experienced; or Patient has been previously treated with a targeted immunomodulator FDA-approved for the treatment o [...]
19 Active Policies
UHC-POL-orencia-abatacept-injection-intravenous-infusion, Orencia (Abatacept) Injection for Intravenous Infusion
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
AETNA-CPB-0720, Abatacept (Orencia)
RX501.113, Abatacept
BCBSIL-RX501.113, Abatacept
BCBSIL-RX502.061, Oncology Medications
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.113, Abatacept
BCBSMT-RX502.061, Oncology Medications
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.113, Abatacept
BCBSNM-RX502.061, Oncology Medications
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.113, Abatacept
BCBSOK-RX502.061, Oncology Medications
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
UMR-POL-UMR-orencia-abatacept-injection-intravenous-infusion, Orencia (Abatacept) Injection for Intravenous Infusion
UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-orencia-abatacept-injection-intravenous-infusion, Orencia (Abatacept) Injection for Intravenous Infusion
Related Codes
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