CommercialPrior AuthMedium impact
Rilonacept (Arcalyst) (CPB 0770, reviewed 2026-09-11)
Aetna·Rheumatology, Cardiology, Allergy & Immunology +1 more·Medical Policy
We identified it
Oct 3, 2026
Summary
Aetna issued a fresh clinical policy (CPB 0770) for Rilonacept (Arcalyst) effective immediately, establishing coverage criteria for three indications: Cryopyrin-associated periodic syndromes (CAPS) in members 12+, Deficiency of interleukin-1 receptor antagonist (DIRA) in members 10kg+, and Recurrent pericarditis (RP) in members 12+. All other uses are considered experimental/investigational. The policy requires specific prescriber credentials by specialty and mandates TB screening before initiation.
Action Required
Immediately: Billing team must implement prior authorization requirements for rilonacept (J2793) claims on Aetna commercial plans. In the billing system, add edits to require: (1) Diagnosis validation for CAPS (FCAS or MWS), DIRA (with IL1RN mutations), or RP (≥2 episodes with documented criteria); (2) Age/weight verification (12+ years for CAPS/RP; 10kg+ for DIRA); (3) Prescriber specialty verification (rheumatologist/immunologist for CAPS/DIRA; cardiologist/rheumatologist/immunologist for RP); (4) Documentation of TB screening completion before dispensing. For RP cases, verify failure of ≥2 standard therapy agents (colchicine, NSAIDs, corticosteroids). For DIRA, confirm prior anakinra (Kineret) treatment. Claims lacking these elements will be denied. Update encounter templates to capture required clinical documentation. Notify rheumatology, cardiology, and immunology providers of specialty-specific requirements and prohibited concomitant biologic use.