Does J0129 require prior authorization?

Yes, J0129 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0129?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J0129`, Injection, abatacept, 10 mg (code may be used for medicare when drug

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Key Coverage Criteria

This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
Orencia IV is medically necessary for: adults with moderately to severely active RA after inadequate response to DMARDs or biologics; adults with active PsA after inadequate response to DMARDs or biologics; children 6+ with polyarticular JIA after inadequate response to DMARDs or biologics; and adults/peds ≥2 undergoing HSCT for GVHD prophylaxis when used with CNI and MTX.
Oncology medications may be considered medically necessary when the drug (a) is FDA-approved for an oncologic indication and used per FDA labeling, or (b) has NCCN Category 1/2A/2B recommendation per NCCN Guidelines or NCCN Compendium.
Initial therapy for polyarticular juvenile idiopathic arthritis requires: diagnosis of moderately to severely active PJIA; Orencia initiated/titrated per FDA-labeled dosing for PJIA; not on Orencia with a targeted immunomodulator; initial authorization max 12 months. Continuation requires: prior Orencia IV injection, documentation of positive response, dosing per FDA labeling for PJIA, not on targeted immunomodulator; authorization max 12 months.
Orencia is proven for the treatment of polyarticular juvenile idiopathic arthritis with initial therapy criteria: diagnosis PJIA, FDA-labeled dosing, not in combination with targeted immunomodulator, and initial authorization up to 12 months; continuation criteria include prior Orencia IV use, positive response, FDA dosing, not in combination with targeted immunomodulator, and up to 12 months.

20 Active Policies

ARKBLUE-ABATACEPT-E-G-ORENCIA-C074AF8768, Abatacept (e.g., Orencia)

FLORIDA_BLUE-FLBLUE-ABATACEPT-ORENCIA-892518D947, Abatacept (Orencia)

BCIDAHO-05-01-671-93E4CECC05, Orencia (abatacept) for Intravenous Use. Medical Policy MP 5.01.671 Orencia (abatacept) for Intravenous Use DISCLAIMER/INSTRUCTIONS FOR USE This medical policy provides general guidance for

BCBSLA-00214-40D0967655, 00214 abatacept (Orencia)

BCBSM-2027124-22EFCA84FF, ORENCIA (ABATACEPT)

POINT32HEALTH-PMNG-24576, Orencia (abatacept) Subcutaneous

MULTI

BCBSND-ABATACEPT-ORENCIA-03ED204E42, Abatacept Orencia

BCBSNJ-DRUGS-042-032BB0E04E, Abatacept (Orencia)

MODA-ORENCIA-AC82B1E3A3, Orencia (abatacept)

IBX-MEDICARE-ADVANTAGE-MA08-028K-85408EEC24, Abatacept (Orencia) for Injection for Intravenous Use

IBX-COMMERCIAL-08-00-62R-AC72747685, Abatacept (Orencia) for Injection for Intravenous Use

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.113, Abatacept

BCBSOK-RX502.061, Oncology Medications

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-orencia-abatacept-injection-intravenous-infusion, Orencia (Abatacept) Injection for Intravenous Infusion

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-orencia-abatacept-injection-intravenous-infusion, Orencia (Abatacept) Injection for Intravenous Infusion

AMERIHEALTH-COMMERCIAL-08-00-62R-BBCF3E5AB0, Abatacept (Orencia) for Injection for Intravenous Use

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-028K-0601EDD77F, Abatacept (Orencia) for Injection for Intravenous Use

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J0129, Injection, abatacept, 10 mg (code may be used for medicare when drug

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Key Coverage Criteria

This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
Orencia IV is medically necessary for: adults with moderately to severely active RA after inadequate response to DMARDs or biologics; adults with active PsA after inadequate response to DMARDs or biologics; children 6+ with polyarticular JIA after inadequate response to DMARDs or biologics; and adults/peds ≥2 undergoing HSCT for GVHD prophylaxis when used with CNI and MTX.
Oncology medications may be considered medically necessary when the drug (a) is FDA-approved for an oncologic indication and used per FDA labeling, or (b) has NCCN Category 1/2A/2B recommendation per NCCN Guidelines or NCCN Compendium.
Initial therapy for polyarticular juvenile idiopathic arthritis requires: diagnosis of moderately to severely active PJIA; Orencia initiated/titrated per FDA-labeled dosing for PJIA; not on Orencia with a targeted immunomodulator; initial authorization max 12 months. Continuation requires: prior Orencia IV injection, documentation of positive response, dosing per FDA labeling for PJIA, not on targeted immunomodulator; authorization max 12 months.
Orencia is proven for the treatment of polyarticular juvenile idiopathic arthritis with initial therapy criteria: diagnosis PJIA, FDA-labeled dosing, not in combination with targeted immunomodulator, and initial authorization up to 12 months; continuation criteria include prior Orencia IV use, positive response, FDA dosing, not in combination with targeted immunomodulator, and up to 12 months.

20 Active Policies

ARKBLUE-ABATACEPT-E-G-ORENCIA-C074AF8768, Abatacept (e.g., Orencia)

FLORIDA_BLUE-FLBLUE-ABATACEPT-ORENCIA-892518D947, Abatacept (Orencia)

BCBSLA-00214-40D0967655, 00214 abatacept (Orencia)

BCBSM-2027124-22EFCA84FF, ORENCIA (ABATACEPT)

POINT32HEALTH-PMNG-24576, Orencia (abatacept) Subcutaneous

MULTI

BCBSND-ABATACEPT-ORENCIA-03ED204E42, Abatacept Orencia

BCBSNJ-DRUGS-042-032BB0E04E, Abatacept (Orencia)

MODA-ORENCIA-AC82B1E3A3, Orencia (abatacept)

IBX-MEDICARE-ADVANTAGE-MA08-028K-85408EEC24, Abatacept (Orencia) for Injection for Intravenous Use

IBX-COMMERCIAL-08-00-62R-AC72747685, Abatacept (Orencia) for Injection for Intravenous Use

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.113, Abatacept

BCBSOK-RX502.061, Oncology Medications

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-orencia-abatacept-injection-intravenous-infusion, Orencia (Abatacept) Injection for Intravenous Infusion

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-orencia-abatacept-injection-intravenous-infusion, Orencia (Abatacept) Injection for Intravenous Infusion

AMERIHEALTH-COMMERCIAL-08-00-62R-BBCF3E5AB0, Abatacept (Orencia) for Injection for Intravenous Use

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-028K-0601EDD77F, Abatacept (Orencia) for Injection for Intravenous Use

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`J0129`, Injection, abatacept, 10 mg (code may be used for medicare when drug

Prior Authorization

Medicare Pricing

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0129`, Injection, abatacept, 10 mg (code may be used for medicare when drug

Prior Authorization

Medicare Pricing

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0129, Injection, abatacept, 10 mg (code may be used for medicare when drug

Prior Authorization

Medicare Pricing

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0129, Injection, abatacept, 10 mg (code may be used for medicare when drug

Prior Authorization

Medicare Pricing

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0129`, Injection, abatacept, 10 mg (code may be used for medicare when drug

`J0129`, Injection, abatacept, 10 mg (code may be used for medicare when drug