Limited Coverage Drugs - Abatacept

Generic Name / Strength / Form
abatacept

Criteria Approval Period
1. Treatment of Rheumatoid Arthritis according to established criteria* when prescribed by a rheumatologist 1 year
2. Treatment of Juvenile Idiopathic Arthritis. 1 year

Practitioner Exemptions

  • Pediatric rheumatologists for pediatric patients diagnosed with rheumatoid arthritis.

Special Notes

  • For the treatment of Juvenile Idiopathic Arthritis:  Initial treatment should be limited to a maximum of 16 weeks and retreatment should only be permitted for children who have had an adequate initial treatment response and subsequently experience a flare.
  • For coverage, the maximum allowable supply of abatacept is 28 days per fill.

Special Authority Request Forms

* Click on the appropriate Special Authority Form below for full criteria.