MediGold
Orencia (abatacept)
(Coverage Determination)
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Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-855-633-7673.
Please contact CVS/Caremark at 1-866-785-5714 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Orencia (abatacept) (Coverage Determination).
Drug Name:
Orencia (abatacept)
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB:
Patient Phone:
Prescribing Physician
Physician Name:
Physician Phone:
Physician Fax:
Physician Address:
City, State, Zip:
Diagnosis: / ICD Code:
Please circle the appropriate answer for each question.
1. / Has the patient previously received Orencia for one of the following conditions?
· Rheumatoid arthritis
· Juvenile idiopathic arthritis (JIA)
[If yes, no further questions.] / Yes / No
2. / Is Orencia prescribed for a patient with moderately to severely active rheumatoid arthritis?
[If no, skip to question 4.] / Yes / No
3. / Does the patient meet one of the following criteria:
· Patient has had an inadequate response, intolerance, or contraindication to methotrexate (MTX), OR
· Patient has had an inadequate response or intolerance to a prior biologic DMARD
[If yes, skip to question 6.]
[If no, no further questions.] / Yes / No
4. / Is Orencia prescribed for a patient with moderately to severely active polyarticular JIA?
[If no, no further questions.] / Yes / No
5. / Does the patient meet one of the following criteria:
· Patient has had an inadequate response to a TNF inhibitor, OR
· Patient has a contraindication or intolerance to TNF inhibitors
[If no, no further questions.] / Yes / No
6. / Prior to initiating treatment with Orencia (or other biologic), has the patient been screened for latent TB infection with either a TB skin test or an interferon gamma release assay (e.g., QFT-GIT, T-SPOT.TB)? / Yes / No
Comments:
I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature and Date