Subject: Specialty Quantity Limit Kevzara 1953-H P2025

Drug

KEVZARA  (sarilumab)

Policy:

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.

Covered Quantities

Medication	Standard Limit
Kevzara (sarilumab) 150 mg/1.14 mL single-dose pre-filled syringe	1 pack (2 x 150 mg syringe) per 4 weeks
Kevzara (sarilumab) 150 mg/1.14 mL single-dose pre-filled pen	1 pack (2 x 150 mg pen) per 4 weeks
Kevzara (sarilumab) 200 mg/1.14 mL single-dose pre-filled syringe	1 pack (2 x 200 mg syringe) per 4 weeks
Kevzara (sarilumab) 200 mg/1.14 mL single-dose pre-filled pen	1 pack (2 x 200 mg pen) per 4 weeks

FDA-Recommended Dosing

Rheumatoid arthritis (adult)

200 mg once every two weeks

Reduce dose to 150 mg once every two weeks for management of neutropenia, thrombocytopenia and elevated liver enzymes

Polymyalgia Rheumatica (adult)

200 mg once every two weeks in combination with a tapering course of corticosteroids

Can be used as monotherapy following discontinuation of corticosteroids

Polyarticular juvenile idiopathic arthritis in patients weighing 63 kg or greater

200 mg once every two weeks using the 200 mg/1.14 mL pre-filled syringe

Place of Service:

Outpatient

The above policy is based on the following references:

1. Kevzara [package insert]. Bridgewater, NJ: Sanofi-aventis, U.S. LLC/Regeneron Pharmaceuticals, Inc.; May 2025.

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.

January 01, 2026