rilonacept — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following: A. The requested agent is eligible for continuation of therapy AND ONE of the following: 1. The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR 2. The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
• BOTH of the following: 1. ONE of the following: A. The patient has a diagnosis of Cryopyrin-Associated Periodic Syndrome (CAPS) AND BOTH of the following: 1. The patient has ONE of the following disorders (phenotypes): A. Familial Cold Autoinflammatory Syndrome (FCAS) OR B. Muckle-Wells Syndrome (MWS) AND 2. BOTH of the following: A. The patient has a history of elevated pretreatment serum inflammatory markers (C-reactive protein/serum amyloid A) AND B. The patient has a history of at least TWO symptoms typical for CAPS (i.e., urticaria-like rash, cold/stress triggered episodes, sensorineural hearing loss, musculoskeletal symptoms, chronic aseptic meningitis, skeletal abnormalities, etc.)