Does J0129 require prior authorization?

No, J0129 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for J0129?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`J0129` — Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

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.

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 [...]

15 Active Policies

AETNA-CPB-0720 — Abatacept (Orencia)

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

UMR-POL-UMR-orencia-abatacept-injection-intravenous-infusion — Orencia (Abatacept) Injection for Intravenous Infusion

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

J0129 — Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)