Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after June 1, 2021, indications for abatacept (Orencia) will change for Texas Medicaid.
Abatacept (Orencia) will be indicated for the following:
- Moderate to severe rheumatoid arthritis in adult clients. Abatacept may be used as monotherapy or concomitantly with disease modifying antirheumatic drugs other than TNF antagonists.
- Moderate to severe juvenile arthritis in adult and pediatric clients who are two years of age and older (clients who are two years of age and older may receive subcutaneous formulation and clients who are six years of age and older may receive intravenous formulation). Abatacept may be used as monotherapy or concomitantly with methotrexate.
- Psoriatic arthritis in adult clients.
Prior authorization requests must include documentation supporting a diagnosis of adult rheumatoid arthritis, juvenile idiopathic arthritis, or adult psoriatic arthritis.
For more information, call the TMHP Contact Center at 800-925-9126.