Limited coverage drugs – abatacept for the treatment of rheumatoid arthritis
Last updated on August 7, 2024
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Generic name |
abatacept |
|---|---|
Strength & form |
250 mg/15 mL intravenous infusion vial |
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). |
1 year |
Practitioner exemptions
- None
Special notes
- Coverage of abatacept for the treatment of RA is only available when abatacept is prescribed by a rheumatologist
- The maximum covered allowable supply of abatacept is 28 days per fill
Special Authority request form(s)
- Log in to eForms
- HLTH 5345 – Abatacept / Adalimumab / Certolizumab / Etanercept / Golimumab / Infliximab / Tocilizumab for Rheumatoid Arthritis - Initial / Switch (PDF, 860KB)
- HLTH 5354 – Abatacept / Adalimumab / Certolizumab / Etanercept / Golimumab / Infliximab / Tocilizumab for Rheumatoid Arthritis - Renewal (PDF, 902KB)
- HLTH 5383 – Health Assessment Questionnaire (HAQ) (PDF, 528KB)