Medicare AdvantagePrior AuthMedium impact
Ilaris® (canakinumab) (Revised)
Humana·Rheumatology, Pediatrics, Internal Medicine +1 more·Medicare Advantage
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana updated its Ilaris (canakinumab) prior authorization policy for Medicare Advantage members effective November 26, 2025. The policy maintains coverage criteria across six indications (CAPS/FCAS/MWS, Still's Disease, TRAPS, FMF, HIDS/MKD, and gout flare) with specific age and clinical thresholds for each condition. The revision date of November 26, 2025 indicates this is a routine policy refresh; however, billing teams must verify all prior authorization requirements are being enforced in claims processing systems.
Action Required
By December 10, 2025: Billing and prior authorization teams must verify that Humana's updated Ilaris (canakinumab) policy is correctly configured in all claim submission and prior authorization systems. Specifically: (1) Ensure prior authorization is required for ALL Ilaris claims for Medicare Advantage members; (2) Verify the system enforces the six covered indications listed in the policy; (3) Confirm age-based criteria are applied (age 4+ for CAPS, age 2+ for Still's Disease); (4) For TRAPS, confirm baseline requirement of >6 flares/year is documented before approval; (5) For FMF, confirm patient has prior treatment/contraindication/intolerance to colchicine; (6) For HIDS/MKD, confirm ≥3 febrile acute flares in 6-month baseline period; (7) For gout flare, confirm intolerance/contraindication to NSAIDs AND colchicine, plus documented reasons corticosteroid courses are inappropriate. Update prior authorization request templates and staff training materials. Obtain written confirmation from your Humana representative that all claims systems reflect the November 26, 2025 version. Failure to enforce these criteria will result in claim denials and payment delays.