Arcalyst (rilonacept) — CareFirst (Caremark)

Cryopyrin-Associated Periodic Syndromes (CAPS) including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS)

Initial criteria

Member age ≥ 12 years
Member has a diagnosis of FCAS with classic signs and symptoms (recurrent, intermittent fever and rash often exacerbated by exposure to generalized cool ambient temperature) OR MWS with classic signs and symptoms (chronic fever and rash of waxing and waning intensity, sometimes exacerbated by exposure to generalized cool ambient temperature)
Member has functional impairment limiting the activities of daily living
Member has had a documented negative tuberculosis (TB) test within 12 months of initiating therapy or treatment completed for latent TB as applicable
Member will not use the requested medication concomitantly with any other biologic drug or targeted synthetic drug
Prescribed by or in consultation with a rheumatologist or immunologist

Member age ≥ 12 years
Member has achieved or maintained a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition

12 months