Arcalyst (rilonacept) — Cigna

Initial criteria

• Patient has a diagnosis of recurrent pericarditis; AND
• Prior to starting treatment with Arcalyst, the patient had a history of at least three episodes of pericarditis; AND
• Patient meets ONE of the following (a or b): a) For the current episode, the patient is receiving standard treatment; OR b) Standard treatment is contraindicated; AND
• Note: Standard treatments for pericarditis include nonsteroidal anti-inflammatory drug(s) [NSAIDs], colchicine, and/or systemic corticosteroids.
• The medication is prescribed by or in consultation with a cardiologist or rheumatologist.

Reauthorization criteria

• Patient has been established on this medication for at least 3 months; AND
• Patient meets at least ONE of the following (a or b): a) When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (prior to initiating the requested drug); OR b) Compared with baseline (prior to initiating the requested drug), patient experienced an improvement in at least one symptom.

Approval duration

1 year