Payer PolicyActive
Rilonacept (Arcalyst)
EVICORE-MEDICAL_DRUG-A5505E89
EviCore by Evernorth
Effective: August 1, 2020
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Arcalyst (rilonacept) is covered only for FDA‑approved cryopyrin‑associated periodic syndromes (CAPS — FCAS and MWS) in patients aged ≥12 and non‑FDA uses are excluded. Initial approval (3 months) requires prescription by or consultation with a rheumatologist, geneticist, allergist, immunologist, or dermatologist with documentation of diagnosis and age (and weight for pediatric dosing), and renewals (12 months) require documented clinical response and adherence to prescribing‑information dosing.
Coverage Criteria Preview
Key requirements from the full policy
"Arcalyst is an interleukin-1 blocker indicated for the treatment of cryopyrin-associated periodic syndromes (CAPS), including familial cold autoinflammatory syndrome (FCAS) and Muckle-Wells syndrom..."
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