IBC will revise the medical policies on Orencia
® (IV),
Actemra
® (IV), and Rituxan
® to update the
coverage criteria for the indication of adult rheumatoid arthritis (RA). The
criteria apply only to commercial (non-Medicare Advantage) members who have
never received a biologic agent as therapy to treat RA.
Effective June 3, 2014, Orencia
® (IV),
Actemra
® (IV), and Rituxan
® will only be eligible
for coverage and reimbursement in the treatment of adult RA when both of the
following criteria are met:
the member meets the medical necessity criteria in the medical policy for that
specific drug; AND
the member has a documented failure, contraindication, or intolerance to
Remicade
®, or there is a clinical reason that a trial of
Remicade
® would be otherwise inappropriate for the member.
For members who are currently receiving Orencia
® (IV),
Actemra
® (IV), or Rituxan
®, these drugs will
continue to be eligible for coverage when they are prescribed in accordance
with the regimen that has been precertified by IBC.
Notification versions of the updated medical policies are available online:
Medical Policy #08.00.50l: Rituximab (Rituxan
®)
Medical Policy #08.00.62e: Abatacept (Orencia
®) for Injection
for Intravenous Use
Medical Policy #08.00.85d: Tocilizumab (Actemra
®) for
Intravenous Infusion
For details on these policies, go to our
Medical Policy Portal, select
Accept
and Go to Medical Policy Online, click on
Policy Notifications, and
then type the policy name or number in the Search box.