Limited coverage criteria – abatacept for rheumatoid arthritis

Last updated on March 6, 2025

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Generic name	abatacept
Strength & form	250 mg/15 mL intravenous infusion vial 125 mg/mL 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 HLTH 5345 (Initial/Switch) and 5354 (Renewal)	1 year

Practitioner exemptions

None

Special notes

Requests for abatacept for the treatment of RA must be submitted by a rheumatologist
The maximum covered allowable supply of abatacept is 28 days per fill

Special Authority request form(s)

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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)

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Limited coverage criteria – abatacept for rheumatoid arthritis

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)