Canakinumab

This policy covers canakinumab (Ilaris®) for treatment of approved autoinflammatory and inflammatory conditions — including CAPS (FCAS, MWS) in patients ≥4 years, TRAPS, HIDS/MKD, FMF, active Still’s disease (AOSD and SJIA) in patients ≥2 years, and gout flares in adults when NSAIDs/colchicine are contraindicated, not tolerated, or ineffective — administered subcutaneously by a clinician. Coverage is limited to FDA‑labeled indications (with off‑label uses only if supported by HHS‑adopted compendia or two peer‑reviewed articles), must follow authoritative dosing/frequency/duration, is subject to the member’s HCSC Ohio benefit plan/contract, and excludes non‑proven, non‑formulary, or contraindicated uses.

"Therapy is covered when it is proven effective for the relevant diagnosis or procedure based on generally accepted standards of practice."

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