Subject: Specialty Quantity Limit Orencia 1977-H P2022
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. If member’s plan
allows a quantity limit exception review for the requested
medication, coverage of an additional quantity may be provided
up to the exception limit with prior authorization.
II. COVERED QUANTITIES
|
Medication
|
Standard
Limit
|
Exception
Limit*
|
FDA-recommended dosing
|
|
Orencia (abatacept)
subcutaneous
injection: 50 mg per
0.4 mL syringe
|
4 syringes
per 28 days
|
N/A
|
• RA and PsA (adult): 125 mg
once weekly
• PJIA
º Weight 10 kg to < 25 kg:
50 mg once weekly
º Weight 25 kg to < 50 kg:
87.5 mg once weekly
º Weight ≥ 50 kg: 125 mg
once weekly
|
|
Orencia (abatacept)
subcutaneous
injection: 87.5 mg
per 0.7 mL syringe
|
4 syringes
per 28 days
|
N/A
|
|
Orencia (abatacept)
subcutaneous
injection: 125 mg
per mL
syringe/autoinjector
|
4 syringes
per 28 days
|
N/A
|
|
Orencia (abatacept)
intravenous: 250 mg
single-use vial
|
4 vials every
28 days
|
16 vials per
29 days
|
• RA and PsA (adult) at week
0, 2, and 4 then every 4
weeks
º Weight < 60 kg: 500 mg
º Weight 60 kg to 100 kg:
750 mg
º Weight > 100 kg: 1000 mg
• PJIA (6 years of age and
older) at week 0, 2, and 4
then every 4 weeks
º Weight < 75 kg: 10 mg
per kg
º Weight ≥ 75 kg: following
the RA/PsA dosing above
• Prophylaxis of aGVHD
º 2 years to less than 6 years
of age: 15 mg/kg on the
day before transplantation
(Day -1), followed by 12
mg/kg on Days 5, 14, and
28 after transplantation
º 6 years of age and older: 10
mg/kg (max 1000 mg) on
the day before
transplantation (Day -1),
followed by administration
on Days 5, 14, and 28 after
transplantation
|
Abbreviations: RA = rheumatoid arthritis; PsA = psoriatic arthritis; PJIA = polyarticular juvenile idiopathic arthritis; aGVHD = acute graft versus host disease
*Loading doses are addressed by the post-limit quantity exceptions criteria.
Place of Service:
Outpatient
The above policy is based on the following references:
- Orencia [package insert]. Princeton, NJ: Bristol-Myers Squibb Co.; December 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
March 28, 2023
