Actemra SC — Medical Mutual
Systemic Sclerosis Associated Interstitial Lung Disease (SSc-ILD)
Initial criteria
- Patient age ≥ 18 years; AND
- Patient has elevated acute phase reactants as evidenced by CRP > 6 mg/mL OR ESR > 28 mm/h OR Platelet count > 330 x 10^9/L; AND
- Medication is prescribed by or in consultation with a rheumatologist or pulmonologist; AND
- Forced vital capacity (FVC) > 55% predicted value; AND
- Diagnosis is confirmed by high-resolution computed tomography; AND
- Site of care medical necessity is met
Reauthorization criteria
- Patient age ≥ 18 years; AND
- Patient has experienced a beneficial clinical response to therapy over previous 1 year; AND
- Medication is prescribed by or in consultation with a rheumatologist or pulmonologist; AND
- Site of care medical necessity is met
Approval duration
initial: 1 year; reauth: 1 year