Arcalyst (rilonacept) — Blue Cross Blue Shield of Alabama

Initial criteria

• ONE of the following:
• 1. Continuation of therapy: patient has been treated with the requested agent (not samples) within the past 90 days OR prescriber states patient has been treated within past 90 days and is at risk if therapy is changed
• 2. Patient has a diagnosis of Cryopyrin-Associated Periodic Syndrome (CAPS) AND BOTH of the following:
• • The patient has ONE of the following phenotypes: Familial Cold Autoinflammatory Syndrome (FCAS) OR Muckle-Wells Syndrome (MWS)
• • BOTH of the following:
• – History of elevated pretreatment serum inflammatory markers (C-reactive protein or serum amyloid A)
• – History of at least TWO symptoms typical for CAPS (urticaria-like rash, cold/stress triggered episodes, sensorineural hearing loss, musculoskeletal symptoms of arthralgia/arthritis/myalgia, chronic aseptic meningitis, skeletal abnormalities of epiphyseal overgrowth/frontal bossing)
• OR
• 3. Patient has a diagnosis of deficiency of interleukin-1 receptor antagonist (DIRA) AND BOTH of the following:
• • Diagnosis confirmed via genetic testing for mutations in the IL1RN gene
• • Requested agent used for maintenance of remission
• OR
• 4. Patient has a diagnosis of recurrent pericarditis AND BOTH of the following:
• • Pericarditis recurs after a symptom-free interval of 4 weeks or longer after an acute pericarditis episode
• • ONE of the following:
• – ALL of the following: patient has tried and had an inadequate response to colchicine after at least a 6-month duration of therapy AND ONE of the following:
• • Colchicine used concomitantly with a nonsteroidal anti-inflammatory drug (NSAID) for at least a 1-week duration of therapy OR
• • Colchicine used concomitantly with aspirin for at least a 1-week duration of therapy