Medicare AdvantagePrior AuthMedium impact
Arcalyst® (rilonacept) (Revised)
Humana·Rheumatology, Internal Medicine, Pediatrics +2 more·Medicare Advantage
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Arcalyst (rilonacept) prior authorization policy effective December 17, 2025, clarifying coverage criteria for three distinct indications: Cryopyrin-Associated Periodic Syndrome (CAPS) including FCAS/MWS (age 12+), recurrent pericarditis (age 12+), and DIRA (no age restriction). The policy maintains prior authorization requirements with plan year approval durations and reinforces contraindications for active/chronic infections and concurrent live vaccines.
Action Required
By December 17, 2025: Billing and prior authorization teams must update internal clinical decision support systems to reflect three separate coverage pathways for Arcalyst with distinct age restrictions and diagnostic criteria. Verify that PA submission templates capture: (1) CAPS diagnosis confirmation for patients age 12+; (2) recurrent pericarditis documentation including symptom-free interval of ≥4 weeks for patients age 12+; or (3) DIRA diagnosis with NO age requirement. Prior to claim submission, ensure providers document exclusion of active/chronic infections (TB, HIV, Hepatitis B/C) and confirm member is not receiving concurrent live vaccines. Claims submitted without proper diagnosis documentation or for patients under age 12 (except DIRA cases) will be denied. Providers should contact Humana's PAL system (www.humana.com/PAL) for specific medical billing codes and prior authorization submission requirements.