Subject: Specialty Quantity Limit Arcalyst 1744-H P2022
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
FDA-recommended dosing
|
|
Arcalyst (rilonacept) injection 220 mg vial
|
8 vials per 28 days
|
Cryopyrin-associated periodic syndrome (CAPS), Familial Cold Auto-inflammatory Syndrome (FCAS), Muckle-Wells Syndrome (MWS), and recurrent pericarditis:
• Adult patients 18 years and older: Loading dose of 320 mg
(2 vials) followed by 160 mg (1 vial) once weekly
• Pediatric patients 12 years to 17 years: Loading dose of
4.4 mg/kg (max 320 mg [2 vials]) followed by 2.2 mg/kg
(max 160 mg) once weekly
Deficiency of interleukin-1 receptor antagonist (DIRA):
• Adult patients 18 years and older: 320 mg once weekly
(2 vials)
• Pediatric patients weighing at least 10 kg: 4.4 mg/kg
(up to a maximum of 320 mg [2 vials]) once weekly
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Arcalyst [package insert]. London, UK: Kiniksa Pharmaceuticals (UK), Ltd.; March 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
June 26, 2022
