Medicare AdvantagePrior AuthMedium impact
Orencia (abatacept) Subcutaneous (Revised)
Humana·Rheumatology, Internal Medicine, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 22, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Orencia (abatacept) subcutaneous injection, effective January 1, 2026. The policy requires prior authorization for three indications (Psoriatic Arthritis, Rheumatoid Arthritis, and Polyarticular Juvenile Idiopathic Arthritis) with specific age requirements and mandatory prior therapy with two drugs from defined lists before Orencia can be approved.
Action Required
By December 15, 2025: Billing team must update prior authorization workflows in the billing system to require PA submission for all Orencia (abatacept) subcutaneous claims for Humana Medicare Advantage members. Rheumatology and internal medicine providers must document that patients meet all three criteria for their specific indication (diagnosis, age requirement, and prior therapy with TWO drugs from the specified lists). Update encounter templates and claim submission checklist to capture: (1) confirmation of active diagnosis with severity level where applicable, (2) member age verification, and (3) documentation of failed or contraindicated prior therapies. Failure to submit prior authorization or provide required documentation will result in claim denials for Humana Medicare Advantage beneficiaries.