Cigna Kevzara Prior Auth Policy Update

Coverage Criteria for Kevzara (sarilumab)

Initial and continuation therapy — Rheumatoid Arthritis

Covered when ONE of the following is met (A or B):

RA - Initial or Continuing: A) Initial Therapy: Approve for 6 months if ALL of the following are met: i) patient is > 18 years of age; AND ii) patient has tried ONE conventional synthetic disease-modifying antirheumatic drug (DMARD) for at least 3 months (examples include methotrexate, leflunomide, hydroxychloroquine, sulfasalazine). Exception: prior 3-month trial of a biologic other than the requested drug can substitute for the conventional DMARD requirement; a biosimilar of the requested biologic does not count; OR iii) the medication is prescribed by or in consultation with a rheumatologist. OR B) Patient is Currently Receiving Kevzara: Approve for 1 year if BOTH of the following are met: i) patient has been established on therapy for at least 6 months; AND ii) patient meets at least ONE of the following: a) patient experienced a beneficial clinical response when assessed by at least one objective measure; OR b) patient experienced an improvement in at least one symptom (e.g., decreased joint pain, morning stiffness, fatigue; improved function; decreased soft tissue swelling).age >18

Examples of objective measures include CDAI, DAS28-ESR/CRP, PASII, RAPID-3, SDAI.

Initial and continuation therapy — Polyarticular Juvenile Idiopathic Arthritis

Covered when ONE of the following is met (A or B):

PJIA - Initial or Continuing: A) Initial Therapy: Approve for 6 months if ALL of the following are met: i) patient weighs ≥ 63 kg; AND ii) patient meets ONE of the following: a) patient has tried one other systemic therapy for this condition (examples include methotrexate, sulfasalazine, leflunomide, or an NSAID); OR b) patient will be starting Kevzara concurrently with methotrexate, sulfasalazine, or leflunomide; OR c) patient has an absolute contraindication to methotrexate, sulfasalazine, or leflunomide (examples: pregnancy, breastfeeding, alcoholic liver disease, immunodeficiency, blood dyscrasias); OR d) patient has aggressive disease as determined by the prescriber; AND iii) the medication is prescribed by or in consultation with a rheumatologist. OR B) Patient is Currently Receiving Kevzara: Approve for 1 year if BOTH of the following are met: i) patient has been established on therapy for at least 6 months; AND ii) patient meets at least ONE of the following: a) when assessed by at least one objective measure (e.g., MD global, PGA, PDA, JDAS, cJDAS, JSpADA, CRP/ESR, or reduced corticosteroid dose) the patient experienced a beneficial clinical response from baseline; OR b) compared with baseline the patient experienced improvement in at least one symptom (e.g., improved range of motion, less joint pain/tenderness, decreased duration of morning stiffness or fatigue, improved function).weight >=63 kg

A prior trial of a biologic other than the requested drug counts as a trial of one systemic therapy; biosimilars do not count.

Initial and continuation therapy — Polymyalgia Rheumatica

Covered when ONE of the following is met (A or B):

PMR - Initial or Continuing: A) Initial Therapy: Approve for 6 months if ALL of the following are met: i) patient is > 18 years of age; AND ii) patient has tried one systemic corticosteroid (example: prednisone); AND iii) the medication is prescribed by or in consultation with a rheumatologist. OR B) Patient is Currently Receiving Kevzara: Approve for 1 year if BOTH of the following are met: i) patient has been established on therapy for at least 6 months; AND ii) patient meets at least ONE of the following: a) when assessed by at least one objective measure (e.g., serum markers such as CRP or ESR, resolution of fever, or reduced corticosteroid dose) the patient experienced a beneficial clinical response from baseline; OR b) compared with baseline the patient experienced improvement in at least one symptom (e.g., decreased shoulder/neck/upper arm/hip/thigh pain or stiffness, improved range of motion, decreased fatigue).age >18

Receipt of sample product does not satisfy criteria; dosage, frequency, duration and site of care should be clinically appropriate.

Use of Kevzara (sarilumab) for indications other than those listed in this policy is considered not medically necessary. The policy specifically cites ankylosing spondylitis as an example where Kevzara did not demonstrate efficacy in a Phase II study and is therefore not covered for that indication. The policy also states that combination therapy with another biologic or a targeted synthetic oral small molecule for an inflammatory condition is not medically necessary.

The appendix provides lists of comparator therapies and their mechanisms of action (for example, agents that inhibit IL‑17A or IL‑23) and example indications for those therapies. These appendix entries do not themselves state explicit exclusions or not‑medically‑necessary determinations; they are informational lists to support clinical review and prior authorization decisions.

Kevzara for any use not detailed in the policy is considered not medically necessary. The policy names ankylosing spondylitis as an explicit example due to lack of efficacy shown in a Phase II trial, and it also specifies that concurrent use with another biologic or a targeted synthetic oral small molecule for an inflammatory condition is not medically necessary.

The appendix content reviewed in these sections contains descriptive listings of therapies, their mechanisms of action, and example indications. These chunks do not include any not medically necessary statements or explicit coverage exclusions; they are presented for informational context only.

Coding and Billing Information

Weight threshold for PJIA (polyarticular juvenile idiopathic arthritis)

Weight threshold for PJIA>= 63 kg

ContextApplies to approval of Kevzara for polyarticular juvenile idiopathic arthritis (PJIA).

Usage in criteriaRequired as part of Initial Therapy criteria: patient weighs ≥63 kg and meets additional therapy or disease criteria.

Source noteThreshold stated in FDA‑Approved Indication for PJIA in overview and criteria sections.

Provider Actions, Requirements, and Operational Notes

Prior Authorization

Prior Authorization Required

Prior Authorization is required for benefit coverage of Kevzara. Initial approvals are generally issued for 6 months for new starts; continuation approvals for patients already receiving Kevzara are generally issued for 1 year. Because of the specialized skills required for evaluation and diagnosis of patients treated with Kevzara as well as monitoring for adverse events and long‑term efficacy, initial authorization requires the medication to be prescribed by or in consultation with a physician who specializes in the condition being treated. This product also requires use of preferred products prior to approval per the referenced Preferred Specialty Management Policies.

Initial approval duration: 6 months (1 month = 30 days)
Continuation approval duration (established patients): 1 year
Prescriber requirement: specialist or documented consultation with a specialist

Documentation Required

Required Documentation

Background

Kevzara (sarilumab) is an interleukin‑6 receptor inhibitor with FDA‑approved indications that include rheumatoid arthritis, polyarticular juvenile idiopathic arthritis (for patients meeting the weight threshold specified in the policy), and polymyalgia rheumatica in adults who have had inadequate response or intolerance to prior therapies. The policy references guideline‑based escalation from conventional DMARDs for biologic use in rheumatoid arthritis and lists objective disease activity measures used to document benefit when continuing therapy.

Definitions and Mechanisms

Kevzara and Appendix Mechanisms of Action

Drug class for Kevzara (sarilumab)Interleukin‑6 (IL‑6) receptor inhibitor

Mechanism of Action — IL‑17A inhibitors (examples)Inhibition of IL‑17A (e.g., secukinumab, ixekizumab)

Mechanism of Action — IL‑23 inhibitors (examples)Inhibition of IL‑23 (e.g., guselkumab, tildrakizumab, risankizumab)

Mechanism of Action — JAK pathway inhibitors (examples)Inhibition of JAK pathways (e.g., upadacitinib, tofacitinib, baricitinib)

Mechanism of Action — TYK2 inhibitor (example)Inhibition of TYK2 (e.g., deucravacitinib)

Mechanism of Action — S1P receptor modulators & PDE4/integrinS1P receptor modulators (e.g., ozanimod, etrasimod); PDE4 inhibitor (apremilast); integrin receptor antagonist (vedolizumab).

Revision History and Policy Changes

2024-11-01policy_created

New policy created (IP0679) with initial documentation of the coverage policy and Summary of Changes = New policy.

2025-05-01administrative_revision

Annual revision noted with no criteria changes (Annual Revision, 2 dated 05/01/2025).

2025-06-01effective_dateLatest

OpenPayer

Kevzara Prior Authorization Policy

Coverage Criteria for Kevzara (sarilumab)

Coding and Billing Information

Provider Actions, Requirements, and Operational Notes

Background

Definitions and Mechanisms

Revision History and Policy Changes