Medicare AdvantagePrior AuthMedium impact
Kineret (anakinra) (Revised)
Humana·SC · Rheumatology, Internal Medicine·Medicaid
Effective date
Jan 1, 2026
We identified it
Jul 1, 2026
Summary
Humana revised its Kineret (anakinra) prior authorization policy effective January 1, 2026, with updates as of June 24, 2026. For rheumatoid arthritis patients, the policy now requires prior authorization with specific criteria: diagnosis of moderately to severely active RA, age 18+, and documented previous treatment failure or intolerance to at least two of three preferred agents (adalimumab products, Enbrel, or Rinvoq). The policy maintains coverage for CAPS (NOMID) and DIRA indications with separate authorization criteria.
Action Required
By December 31, 2025: Billing and clinical teams must implement updated prior authorization processes for all Kineret subcutaneous syringe claims. (1) Update billing system and prior auth submission templates to require documentation of: moderately to severely active RA diagnosis, patient age verification (18+), and evidence of prior treatment failure or documented contraindication/intolerance to TWO of the following: preferred adalimumab products (Humira, adalimumab-adbm, adalimumab-adaz), Enbrel, or Rinvoq. (2) Providers must attach clinical notes and treatment history with each prior auth request demonstrating the two failed DMARD/biologic trials. (3) Prior auth reviewers should use the revised three-part criteria checklist for RA cases. (4) For CAPS (NOMID) and DIRA cases, verify NOMID or DIRA diagnosis documentation separately per policy. (5) Alert prescribing providers that TNF inhibitors used concurrently with Kineret are NOT recommended per policy warnings. Failure to obtain prior authorization or meet criteria will result in claim denials. Note: This policy applies to Medicaid members in South Carolina and Medicare members covered under Humana plans.