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Medical Policy: 05.01.11
Original Effective Date: May 2006
Reviewed: August 2007
Revised: March 2007
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
Abatacept, marketed under the trade name Orencia®, is a selective co stimulation modulator, administered by IV infusion, which inhibits T-cell activation and interrupts the process leading to inflammation in rheumatoid arthritis. In 2005, the US Food and Drug Administration approved abatacept for reducing signs and symptoms, inducing major clinical response, slowing the progression of structural damage, and improving physical function in patients with moderately to severely active rheumatoid arthritis that has failed to adequately respond to one or more disease modifying anti-rheumatoid drugs (DMARDs) or tumor necrosis factor (TNF) antagonists.
Prior Approval is recommended. Submit a prior approval/treatment request now.
Policy:
Abatacept may be considered medically necessary when used as monotherapy or concomitantly with DMARDs other than TNF antagonists, in patients with moderately to severely active rheumatoid arthritis who have had an inadequate or allergic response to one or more DMARDs.
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Procedure Codes and Billing
Guidelines:
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Selected References:
- Genovese MC, Becker JC, Schiff M et al. Abatacept for rheumatoid arthritis refractory to tumor necrosis factor alpha inhibition. N Engl J Med. 2005;353(11):1114-23.
- Kremer JM, Dougados M, Emery P et al. Treatment of rheumatoid arthritis with the selective costimulation modulator abatacept: twelve-month results of a phase iib, double-blind, randomized, placebo-controlled trial. Arthritis Rheum. 2005;52(8):2263-71.
- Allison C. Abatacept as add-on therapy for rheumatoid arthritis. Issues Emerg Health Technol. 2005;73:1-4.
- Emery P. Abatacept has beneficial effects in rheumatoid arthritis patients with an inadequate response to anti-TNF alpha therapy. Clin Exp Rheumatol. 2005;23(6):767-8.
- Teng GG, Turkiewicz AM, Moreland LW, Abatacept: a costimulatory inhibitor for treatment of rheumatoid arthritis. Expert Opin Biol Ther. 2005;5(9):1245-54.
- Ruderman EM, Pope RM, The evolving clinical profile of abatacept (CTLA4-Ig): a novel co-stimulatory modulator for the treatment of rheumatoid arthritis. Arthritis Res. Ther. 2005;7(Suppl 2):S21-5.
- Emery P; Kosinski m;Treatment of Rheumatoid Arthritis patient with abatacept and Methotrexate significantly improve the quality of life. J Rheumatol 2006 Apr:33(4):681-9.
- Kremer JM; Genant HK; Effects of Abatacept inpatients with methotrexate-Resistant Active Rheumatoid Arthritis. Annals of Internal Medicine 2006 June144(12):865-76.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Prior Approval is recommended.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark 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 Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
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