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Indications for Abatacept (Orencia) to Change for Texas Medicaid September 1, 2022

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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 September 1, 2022, indications for abatacept (Orencia) will change for Texas Medicaid.

New Indication for Abatacept (Orencia)

In addition to current indications, abatacept (Orencia) will be indicated for the prophylaxis of acute graft versus host disease (aGVHD).

Prior authorization will be considered when the following criteria are met:

  • The client is two years of age or older.
  • Abatacept (Orencia) is used in combination with a calcineurin inhibitor and methotrexate.
  • The client is undergoing hematopoietic stem cell transplantation from a matched or 1 allele-mismatched unrelated donor.

Prior Authorization Updates

Prior authorization criteria will change for abatacept (Orencia).

Updates for All Indications

Supporting documentation must be submitted with the prior authorization request and must include all of the following:

  • Dates of treatment
  • The number of anticipated doses
  • The dosage to be administered
  • Diagnosis of adult rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), or adult psoriatic arthritis (PsA)
  • Evidence that the drug will be used as prophylaxis of aGVHD

Screening for latent tuberculosis infection and viral hepatitis should be carried out prior to therapy initiation.

Prior authorization may be given for an initial six months for eight doses. Prior authorization for subsequent dosing may be given when documentation supports medical necessity for continued treatment with abatacept (Orencia).

Subsequent prior authorization requests must include all of the following:

  • Documentation from the physician stating that there has been an improvement
  • The number of anticipated doses
  • The dosage to be administered

Criteria for Adult Rheumatoid Arthritis

For treatment of moderate to severe RA in adult clients, concomitant use of abatacept (Orencia) with other immunosuppressives (e.g., biologic disease modifying antirheumatic drugs, Janus kinase inhibitors) is not recommended. Concomitant use with a tumor necrosis factor antagonist can increase the risk of infections and serious infections.

A diagnosis of RA must conform to the American College of Rheumatology RA classification that requires the following:

  • Presence of synovitis in at least one joint
  • Absence of an alternative diagnosis to explain the synovitis
  • Indication that abatacept (Orencia) will not be used in combination with another biologic agent
  • A combined score of at least six out of ten on the level of involved joints, abnormality, and symptom duration from the individual scores in four domains:
  • The number and sites of involved joints
  • Serologic abnormality
  • Elevated acute-phase response
  • Symptom duration

Criteria for Juvenile Idiopathic Arthritis

Prior authorization for moderate to severe JIA will be considered when the following criteria are met:

  • The client is an adult or pediatric client who is two years of age or older.
  • Clients who are two years of age or older may receive subcutaneous formulation, and clients who are six years of age or older may receive intravenous formulation.
  • Abatacept (Orencia) may be used as monotherapy or concomitantly with methotrexate.

Criteria for Adult Psoriatic Arthritis

Prior authorization for PsA will be considered when the following criteria are met:

  • The client is 18 years of age or older.
  • Abatacept (Orencia) will not be used in combination with another biologic agent.

For more information, call the TMHP Contact Center at 800-925-9126.