CommercialCoverageMedium impact
Rilonacept (Arcalyst) (CPB 0770, reviewed 2026-03-25)
Aetna·Rheumatology, Cardiology, Allergy & Immunology +1 more·Medical Policy
Effective date
Mar 25, 2026
We identified it
Aug 16, 2026
Summary
Aetna updated its clinical policy for Rilonacept (Arcalyst) effective 2026-03-25, establishing coverage criteria for three specific indications: Cryopyrin-associated periodic syndromes (CAPS) for ages 12+, Deficiency of interleukin-1 receptor antagonist (DIRA) for patients 10kg+, and Recurrent pericarditis (RP) for ages 12+. All other uses remain experimental/investigational. Prescribing must be by rheumatologist, immunologist, or cardiologist depending on indication.
Action Required
By March 25, 2026: Billing team must implement prior authorization requirements for J2793 (Rilonacept) claims through Aetna commercial plans. Update billing system to verify: (1) member age ≥12 years (or ≥10kg for DIRA), (2) diagnosis is CAPS, DIRA, or RP only, (3) specialist prescriber documented (rheumatologist, immunologist, or cardiologist), (4) TB screening documented within 12 months (TST or IGRA per codes 86480, 86481, or 86580), and (5) no concomitant biologic/targeted synthetic drugs documented. For RP claims, verify documentation of ≥2 prior pericarditis episodes and failure of ≥2 standard therapies. For DIRA, verify IL1RN mutations and prior anakinra treatment. Deny claims for all other indications as experimental. Flag any J2793 claims without proper authorization for rejection. Notify providers that first injection must be supervised; update encounter forms to capture required clinical criteria.