Limited Coverage Drugs - Abatacept for the treatment of Rheumatoid Arthritis

Generic Name

      abatacept

Strength

  1. 250 mg / 15 ml
  2. 125 mg / ml
Form
  1. intravenous infusion vial
  2. subcutaneous injection solution

Special Authority Criteria

Approval Period

For the treatment of Rheumatoid Arthritis (RA) according to established criteria requirements described in the below Special Authority Request forms 5345 (Initial/Switch) and 5354 (Renewal).
 

Coverage of abatacept for the treatment of RA is only available when abatacept is prescribed by a rheumatologist.

1 year

Practitioner Exemptions

  • None

Special Notes

  • The maximum covered allowable supply of abatacept is 28 days per fill.

Special Authority Request Form(s)