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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.9 Abatacept (Orencia)

9.2.39.9
Abatacept is a synthetic protein produced by recombinant deoxyribonucleic acid (DNA) technology that is used for treating rheumatoid arthritis. Abatacept slows the damage to bones and cartilage and relieves the symptoms and signs of arthritis. Abatacept is a benefit of Texas Medicaid for clients who have moderately to severely active rheumatoid arthritis. These clients may also have an inadequate response to one or more non-biological, disease modifying antirheumatic drugs (DMARDs).
9.2.39.9.1
Prior authorization may be given for an initial six months for eight doses. Prior authorization for an initial request for abatacept injections will be considered when all of the following criteria are met:
Note:
Prior authorization for an initial request for abatacept injections may be granted for six months for eight doses. Prior authorization will be considered when the client has an inadequate response after 12 weeks to a nonbiological DMARD such as methotrexate or sulfasalazine or one or more biological (injectable) DMARDs, such as adalimumab, etanercept, or tumor necrosis factor (TNF) antagonists. The inadequate response must be indicated by all of the following commonly used prognostic factors:
Prior authorization for subsequent dosing may be given for a maximum of six doses when documentation supports medical necessity for continued treatment with abatacept. Prior authorization for a subsequent request must include all of the following:
The documentation of medical necessity must be maintained by the requesting provider in the client’s medical record and is subject to retrospective review.

Texas Medicaid & Healthcare Partnership
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