Independence is changing how we manage the biologics that are approved by the U.S. Food and Drug Administration (FDA) for the treatment of polyarticular juvenile idiopathic arthritis (pJIA) for members enrolled in our commercial (non-Medicare Advantage) products. There are various biologics on the market, and there is no reliable evidence that demonstrates the superiority of one biologic over the others. However, there are notable differences in cost.
Coverage criteria
Effective March 8, 2021, the coverage criteria for the indication of pJIA will be updated for Independence's medical policies on Orencia® (IV) and Actemra® (IV) to reflect that Simponi Aria® is the preferred biologic for pJIA. Simponi Aria was selected based on its demonstrated cost-effectiveness and treatment of pJIA. The criteria apply only to commercial (non-Medicare Advantage) members who have never received a biologic agent as therapy to treat pJIA.
Orencia (IV) and Actemra (IV) will only be eligible for coverage and reimbursement in the treatment of pJIA when both of the following criteria are met:
- the member meets the medical necessity criteria in the medical policy for that specific drug;
- the member has a documented failure, contraindication, or intolerance to Simponi Aria, or there is a clinical reason that a trial of Simponi Aria would be otherwise inappropriate for the member.
For members who are currently receiving Orencia (IV) or Actemra (IV) for pJIA, these drugs will continue to be eligible for coverage when they are prescribed in accordance with the regimen that has been precertified by Independence.
Updated policies
For more information, please review the following Independence commercial policies, which were posted as Notifications on December 8, 2020, and will go into effect on March 8, 2021:
- #08.00.62l: Abatacept (Orencia®) for Injection for Intravenous Use
- #08.00.85k: Tocilizumab (Actemra®) for Intravenous Infusion
To view these policy Notifications, visit our Medical and Claim Payment Policy Portal and select Commercial from the Active Notifications section.