Arcalyst (rilonacept) — CareFirst (Caremark)

Initial criteria

• Member age ≥ 12 years
• Member has had at least two episodes of pericarditis
• Member has failed at least two agents of standard therapy (e.g., colchicine, non-steroidal anti-inflammatory drugs [NSAIDs], corticosteroids)
• 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 cardiologist, rheumatologist, or immunologist

Reauthorization criteria

• Member age ≥ 12 years
• Member achieves or maintains a positive clinical response as evidenced by decreased recurrence of pericarditis or improvement in signs and symptoms of the condition when there is improvement in any of the following: pericarditic or pleuritic chest pain, pericardial or pleural rubs, ECG, pericardial effusion, or C-reactive protein (CRP)

Approval duration

12 months