Kevzara (sarilumab) — United Healthcare

moderately to severely active rheumatoid arthritis

Initial criteria

Diagnosis of moderately to severely active rheumatoid arthritis
AND Patient has had an inadequate response or intolerance to one or more disease-modifying anti-rheumatic drugs (DMARDs) (e.g., methotrexate, leflunomide, sulfasalazine)
AND Patient is not receiving Kevzara in combination with another targeted immunomodulator [e.g., adalimumab, Cimzia (certolizumab), Enbrel (etanercept), Olumiant (baricitinib), Orencia (abatacept), Rinvoq (upadacitinib), Simponi (golimumab), Xeljanz/Xeljanz XR (tofacitinib)]

Documentation of positive clinical response to Kevzara therapy
AND Patient is not receiving Kevzara in combination with another targeted immunomodulator [e.g., adalimumab, Cimzia (certolizumab), Enbrel (etanercept), Olumiant (baricitinib), Orencia (abatacept), Rinvoq (upadacitinib), Simponi (golimumab), Xeljanz/Xeljanz XR (tofacitinib)]

12 months