• https://packageinserts.bms.com/pi/pi_orencia.pdf

8. Does the documentation support an approved diagnosis of Adult Rheumatoid Arthritis, Adult Psoriatic Arthritis, or Juvenile Idiopathic Arthritis?

Yes No

• https://packageinserts.bms.com/pi/pi_orencia.pdf

9. Does the documentation support a 3-month trial of oral agent or IV agent that failed, or other indication?

Yes No

Progress note or medical record should support 3-month trial of oral agent, IV agent that failed, or other indication based on medical standard of care

10. Does the dosage and administration meet FDA approved guidelines?

Yes No

• https://packageinserts.bms.com/pi/pi_orencia.pdf

11. Is one of the follow stated as medically necessary reason not to give SQ, such as:

• Age related (17 years and younger IV only)
• Patient/PCG mentally or medically impaired to self-inject (crippled hands), to learn self-injections (dementia), no available caregivers
• Patient may have condition flare and requires IV does(s) to obtain remission
• Patient may have skin condition more susceptible for infection
• Physician documentation specifying rationale

Yes No

Documentation must indicate if after initial intravenous (IV) dose, subcutaneous (SQ) is appropriate for future doses or contain a stated medically necessary reason not to give SQ

• https://packageinserts.bms.com/pi/pi_orencia.pdf