COVERED USES:

FDA-Approved Indications:

Rhematoid Arthritis - Reducing the signs and symptoms and slowing the progression of structural damage in moderate to severe active Rheumatoid Arthritis.

All FDA- approved indications not otherwise excluded from Part D are covered.

AGE RESTRICTIONS:

Must be 18 years or older.

PRESCRIBER RESTRICTIONS:

Must be prescribed by or in consultation with a rheumatologist.

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, documentation of successful response to the medication may be necessary.

CRITERIA:

Anakinra will be approved for RA when all of the following conditions are met:

• Documented failure of methotrexate and a Tumor Necrosis Factor Antagonist (Humira®, Enbrel®, Remicade®).
• Dosing must be within Package Insert guidelines.

Reauthorization will require documentation of adequate response to treatment.

EXCLUSION CRITERIA:

Use in combination with a TNF antagonist agent.

COVERAGE DURATION:

Initial authorization will be approved for up to six months. Reauthorization will be approved for up to one year.