Abatacept (Orencia) Reference Number: ERX.SPA.123 Effective Date: 10.01.16 Last Review Date: 11.17 Revision Log

Clinical Policy: Abatacept (Orencia) Reference Number: ERX.SPA.123 Effective Date: 10.01.16 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description Abatacept (Orencia®) is a selective T cell co-stimulation modulator. FDA Approved Indication(s) Orencia is indicated for: Reducing signs and symptoms, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function in adult patients with moderately to severely active rheumatoid arthritis (RA). Orencia may be used as monotherapy or concomitantly with disease- modifying antirheumatic drugs (DMARDs) other than tumor necrosis factor (TNF) antagonists Reducing signs and symptoms in patients 2 years of age and older with moderately to severely active polyarticular juvenile idiopathic arthritis (pJIA). Orencia may be used as monotherapy or concomitantly with methotrexate (MTX) Treatment of adult patients with active psoriatic arthritis (PsA) Limitation(s) of use: Orencia should not be administered concomitantly with TNF antagonists. Orencia is not recommended for use concomitantly with other biologic RA therapy, such as anakinra. Policy/Criteria Provider must submit documentation (which may include office chart notes and lab results) supporting that member has met all approval criteria It is the policy of health plans affiliated with Envolve Pharmacy Solutions™ that Orencia is medically necessary when the following criteria are met: I. Initial Approval Criteria A. Rheumatoid Arthritis (must meet all): 1. Diagnosis of RA; 2. Prescribed by or in consultation with a rheumatologist; 3. Age ≥ 18 years; 4. Member meets one of the following (a or b): a. Failure of a trial of MTX (at up to maximally indicated doses) used for ≥ 3 consecutive months, unless contraindicated or clinically significant adverse effects are experienced; b. If intolerance or contraindication to MTX, failure of a trial of sulfasalazine or 1 other conventional DMARD (at up to maximally indicated doses) used for ≥ 3 consecutive months, unless contraindicated or clinically significant adverse effects are experienced (see Appendix D); 5. Failure of etanercept (Enbrel is preferred) AND adalimumab (Humira is preferred), each trialed for ≥ 3 consecutive months, unless contraindicated or clinically significant adverse effects are experienced; *Prior authorization is required for etanercept and adalimumab 6. Dose does not exceed the following: a. Intravenous (IV): i. < 60 kg: 500 mg at weeks 0, 2, and 4, then every 4 weeks thereafter; ii. 60-100 kg: 750 mg at weeks 0, 2, and 4, then every 4 weeks thereafter; iii. > 100 kg: 1000 mg at weeks 0, 2, and 4, then every 4 weeks thereafter; b. Subcutaneous (SC): 125 mg once weekly. Approval duration: 6 months B. Polyarticular Juvenile Idiopathic Arthritis (must meet all): Page 1 of 7 CLINICAL POLICY Abatacept 1. Diagnosis of active pJIA; 2. Prescribed by or in consultation with a rheumatologist; 3. Age ≥ 2 years; 4. Member meets one of the following (a or b): a. Failure of a trial of MTX used for ≥ 3 consecutive months unless contraindicated or clinically significant adverse effects are experienced; b. If intolerance or contraindication to MTX, failure of sulfasalazine or leflunomide used for ≥ 3 consecutive months unless contraindicated or clinically significant adverse effects are experienced; 5. Failure of etanercept (Enbrel is preferred) AND adalimumab (Humira is preferred), each trialed for ≥ 3 consecutive months, unless contraindicated or clinically significant adverse effects are experienced; *Prior authorization is required for etanercept and adalimumab 6. For members 2 to 5 years of age, prescribed route of administration is SC; 7. Dose does not exceed the following: a. IV: i. < 75 kg: 10 mg/kg at weeks 0, 2, and 4, then every 4 weeks thereafter; ii. ≥ 75 kg: 1000 mg every 2 weeks for 3 doses (i.e., a dose at weeks 0, 2, and 4), and then every 4 weeks thereafter; b. SC: i. 10 to <25 kg: 50 mg once weekly; ii. 25 to <50 kg: 87.5 mg once weekly; iii. ≥ 50 kg: 125 mg once weekly. Approval duration: 6 months C. Psoriatic Arthritis (must meet all): 1. Diagnosis of active PsA; 2. Prescribed by or in consultation with a dermatologist or rheumatologist; 3. Age ≥ 18 years; 4. Member meets one of the following (a or b): a. Failure of a trial of MTX for ≥ 3 consecutive months unless contraindicated or clinically significant adverse effects are experienced; b. If intolerance or contraindication to MTX, failure of a trial of sulfasalazine, leflunomide, or cyclosporine for ≥ 3 consecutive months unless contraindicated or clinically significant adverse effects are experienced; 5. Failure of etanercept (Enbrel is preferred) AND adalimumab (Humira is preferred), each trialed for ≥ 3 consecutive months, unless contraindicated or clinically significant adverse effects are experienced; *Prior authorization is required for etanercept and adalimumab 6. Dose does not exceed the following: a. IV: i. < 60 kg: 500 mg at weeks 0, 2, and 4, then every 4 weeks thereafter; ii. 60-100 kg: 750 mg at weeks 0, 2, and 4, then every 4 weeks thereafter; iii. > 100 kg: 1000 mg at weeks 0, 2, and 4, then every 4 weeks thereafter; b. SC: 125 mg once weekly. Approval duration: 6 months D. Other diagnoses/indications 1. Refer to ERX.PA.01 if diagnosis is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized). II. Continued Approval A. All Indications in Section I (must meet all): 1. Currently receiving medication via a health plan affiliated with Envolve Pharmacy Solutions or member has previously met initial approval criteria; Page 2 of 7 CLINICAL POLICY Abatacept 2. Member is responding positively to therapy (e.g., labs, sign/symptom reduction, no disease progression, no significant toxicity); 3. If request is for a dose increase, new dose does not exceed the following: a. For RA and PsA: i. IV: a) < 60 kg: 500 mg every 4 weeks; b) 60-100 kg: 750 mg every 4 weeks; c) > 100 kg: 1000 mg every 4 weeks; ii. SC: 125 mg once weekly; b. For pJIA: i. IV: a) < 75 kg: 10 mg/kg every 4 weeks; b) ≥ 75 kg: 1000 mg every 4 weeks; ii. SC: a) 10 to <25 kg: 50 mg once weekly; b) 25 to <50 kg: 87.5 mg once weekly; c) ≥ 50 kg: 125 mg once weekly. Approval duration: 12 months B. Other diagnoses/indications (must meet 1 or 2): 1. Currently receiving medication via a health plan affiliated with Envolve Pharmacy Solutions and documentation supports positive response to therapy. Approval duration: Duration of request or 6 months (whichever is less); or 2. Refer to ERX.PA.01 if diagnosis is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized). III. Diagnoses/Indications for which coverage is NOT authorized: A. Non-FDA approved indications, which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to the off-label use policy – ERX.PA.01 or evidence of coverage documents. IV. Appendices/General Information Appendix A: Abbreviation/Acronym Key ACPA: anti-citrullinated protein antibody MTX: methotrexate ACR: American College of Rheumatology pJIA: polyarticular juvenile idiopathic arthritis CRP: C-reactive protein PsA: psoriatic arthritis DMARDs: disease-modifying antirheumatic drugs RA: rheumatoid arthritis ESR: erythrocyte sedimentation rate RF: rheumatoid factor FDA: Food and Drug Administration SC: subcutaneous IV: intravenous TNF: tumor necrosis factor Appendix B: The 2010 ACR Classification Criteria for RA Classification criteria for RA (score-based algorithm: add score of categories A through D; a score of ≥ 6 out of 10 is needed for classification of a patient as having definite RA) Score A Joint involvement 1 large joint 0 2-10 large joints 1 1-3 small joints (with or without involvement of large joints) 2 4-10 small joints (with or without involvement of large joints) 3 > 10 joints (at least one small joint) 5 B Serology (at least one test result is needed for classification) Negative rheumatoid factor (RF) and negative anti-citrullinated protein antibody 0 (ACPA) Low positive RF or low positive ACPA 2 Page 3 of 7 CLINICAL POLICY Abatacept Classification criteria for RA (score-based algorithm: add score of categories A through D; a score of ≥ 6 out of 10 is needed for classification of a patient as having definite RA) Score High positive RF or high positive ACPA 3 C Acute phase reactants (at least one test result is needed for classification) Normal C-reactive protein (CRP) and normal erythrocyte sedimentation rate (ESR) 0 Abnormal CRP or normal ESR 1 D Duration of symptoms < 6 weeks 0 ≥ 6 weeks 1 Appendix C: Definition of MTX or DMARD Failure In RA, failure of MTX or DMARD is defined as < 50% decrease in swollen joint count, < 50% decrease in tender joint count, and < 50% decrease in ESR, or < 50% decrease in CRP. Appendix D: Therapeutic Alternatives Drug Name Dosing Regimen Dose Limit/ Maximum Dose methotrexate Rheumatoid Arthritis Adults: 30 mg/week (Rheumatrex) 7.5 mg/week PO or 2.5 mg PO Q12 hr for 3 doses/week Children: 15 mg/m2/week Juvenile Idiopathic Arthritis 10-15 mg/m2/week Psoriatic Arthritis 7.5 to 15 mg/week PO sulfasalazine Rheumatoid Arthritis 5 g/day (Azulfidine) 2 gm/day PO in divided doses Juvenile Idiopathic Arthritis 30-50 mg/kg/day PO in two divided doses Psoriatic Arthritis 2,000 mg/day PO leflunomide Rheumatoid Arthritis 100 mg/day (Arava) 100 mg PO QD for 3 days, then 20 mg PO QD Juvenile Idiopathic Arthritis 10-20

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