Medicare AdvantagePrior AuthMedium impact
Kevzara (sarilumab) (Revised)
Humana·Rheumatology, Internal Medicine, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 1, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Kevzara (sarilumab) effective January 1, 2026, with updates as of June 24, 2026. The policy establishes specific clinical criteria for coverage across three indications: moderate to severe rheumatoid arthritis (requires 2 prior therapy failures/contraindications), polymyalgia rheumatica (requires 1 prior corticosteroid therapy/contraindication), and polyarticular juvenile idiopathic arthritis in patients ≥63 kg (requires 2 prior therapy failures/contraindications). All Kevzara requests require prior authorization before dispensing.
Action Required
By January 1, 2026: Billing and prior authorization teams must implement the following: (1) Verify all Kevzara (sarilumab) subcutaneous syringe and pen injector requests require prior authorization submission to Humana Medicare Advantage plans before dispensing; (2) For rheumatoid arthritis patients, require documentation of failed trials or contraindications with TWO of these agents: preferred adalimumab products (Humira, adalimumab-adbm, adalimumab-adaz), Enbrel, or Rinvoq, plus confirmation patient is ≥18 years old; (3) For polymyalgia rheumatica patients, require documentation of prior corticosteroid therapy (e.g., prednisone, methylprednisolone) failure or contraindication to ALL corticosteroids, plus confirmation patient is ≥18 years old; (4) For polyarticular juvenile idiopathic arthritis patients, require confirmation of active diagnosis, weight ≥63 kg, and failed trials or contraindications with TWO of the three preferred agents listed above; (5) Include Black Box Warning acknowledgment in prior auth documentation noting serious infection risks, TB screening requirements, GI perforation risks, and laboratory monitoring requirements (ANC, platelets, liver function, lipids); (6) Update pharmacy system and prior auth submission forms to capture all required clinical criteria. Pharmacy staff must verify all criteria before submitting PA requests; failure to obtain prior authorization will result in claim denials.