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Coverage criteria policies

Canakinumab (ILARIS®) – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Canakinumab (ILARIS) requires prior authorization from HealthPartners Pharmacy Administration. The setting of drug administration will be reviewed as part of the prior authorization.

Coverage

Canakinumab (Ilaris) is generally covered subject to the indications listed below when all of the following criteria are met, and per member plan documents.

Initial Authorizations:
  1. Patients diagnosed with any one of the following with qualifications
    1. 2 years and older with Active Systemic Juvenile Idiopathic Arthritis (SJIA); or
    2. 4 years of age and older with Cryopyrin-Associated Periodic Syndromes (CAPS), including Familial Cold Auto-inflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS), or,
    3. Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS); or,
    4. Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD); or,
    5. Familial Mediterranean Fever (FMF); and,
  2. The patient and/or guardian has attested that they will adhere to the treatment plan; and,
  3. Ilaris is prescribed within the FDA-approved dosing regimen.

Initial authorizations will be approved for 12 months.

Reauthorizations:

Annual reauthorizations will require medical chart documentation that the patient has been seen within the past 12 months and that markers or symptoms of disease are improved by therapy. These include but may not be limited to reduced symptoms of disease and inflammatory markers, including serum C-reactive protein for Periodic Fever Syndromes or normalization of erythrocyte sedimentation rate for SJIA.

Reauthorizations will be approved for 12 months.

Definitions

ILARIS is an interleukin-1β blocker indicated for the treatment of:

Periodic Fever Syndromes:

    · Cryopyrin-Associated Periodic Syndromes (CAPS), in adults and children 4 years of age and older including:

      o Familial Cold Autoinflammatory Syndrome (FCAS)

      o Muckle-Wells Syndrome (MWS)

    · Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) in adult and pediatric patients.

    · Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD) in adult and pediatric patients.

    · Familial Mediterranean Fever (FMF) in adult and pediatric patients.

Active Systemic Juvenile Idiopathic Arthritis (SJIA) in patients aged 2 years and older.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:
HCPCS

Codes

Description

J0638

Injection, canakinumab, 1 mg

NDC

Codes

Description

00078058261

Ilaris 150 MG SOLR

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. “ILARIS” package insert. Novartis Pharmaceuticals Corporation, East Hanover, NJ. 12/2016.

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Policy activity

  • 11/05/2018 - Date of origin
  • 01/01/2019 - Effective date

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