CurrentMass General Brigham Health PlanPolicy N/A

Kevzara (sarilumab) prior authorization

Pharmacy benefit prior authorization requirements for Kevzara (sarilumab) for commercial/exchange members, including diagnosis-specific coverage criteria, continuation criteria, and quantity limits; applies to specialty pharmacy dispensing.

Policy Summary

PayerMass General Brigham Health Plan

PolicyKevzara (sarilumab) prior authorization

Policy CodePolicy N/A

Change TypeClarification (administrative wording)

Effective Date05/01/2026

Next Review DateN/A

Key ActionObtain prior authorization and submit medical records (e.g., chart notes) demonstrating current treatment for new members or clinical improvement/low disease activity for reauthorization.

SourceLink

POLICY UPDATE CHANGES

Changed reauthorization verbiage to 'submission of medical records (e.g., chart notes...)' and updated language for members new to the Plan.

Commercial/Exchangeapplicable plan

24 monthsstandard approval duration

1 pack/4 wksquantity limit

Specialty pharmacydispensing requirement

Coverage Criteria for Kevzara (sarilumab)

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Moderately to severely active rheumatoid arthritis (RA)

Authorization may be granted when ALL of the following diagnosis-specific criteria have been met (or for new-to-plan members with medical records showing current treatment):

New-to-plan exception: If member is new to the plan (coverage effective date ≤ 90 days), submission of medical records documenting the member is currently receiving the requested drug (excluding product obtained as samples or via manufacturer patient assistance programs) satisfies requirement.

Chunk 2

RA main criteria: Diagnosis of moderately to severely active rheumatoid arthritis (RA)

Chunk 3.1

RA prior biologic/JAK trials A: Member has trial and failure, contraindication, or intolerance to TWO of: Cimzia; Enbrel; Humira (Abbvie), Hadlima, Simlandi, Yuflyma; Rinvoq; Simponi; Xeljanz or Xeljanz XR.

Chunk 3.2

RA prior biologic trials B: Member has trial and failure, contraindication, or intolerance to BOTH of: Tyenne; Orencia.

Chunk 3.3

RA conventional therapy: Minimum 3-month trial and failure, contraindication, or intolerance to ONE of the following conventional therapies at maximally tolerated doses: Methotrexate; Leflunomide; Sulfasalazine.3 months

Chunk 3.4

Active polyarticular juvenile idiopathic arthritis (pJIA)

Authorization for pJIA may be granted when ALL following criteria are met:

pJIA diagnosis: Diagnosis of active polyarticular juvenile idiopathic arthritis (pJIA)

Chunk 4.1

pJIA conventional therapy: Minimum duration of a 6-week trial and failure, intolerance, or contraindication to ONE of the following conventional therapies at maximally tolerated doses: Leflunomide; Methotrexate.6 weeks

Chunk 4.2

pJIA prior biologic/JAK trials: Member has trial and failure, contraindication, or intolerance to TWO of: Cimzia; Enbrel; Humira (Abbvie), Hadlima, Simlandi, Yuflyma; Xeljanz; Rinvoq or Rinvoq LQ.

Chunk 4.3

Polymyalgia Rheumatica (PMR)

Authorization for PMR may be granted when ALL following criteria are met:

PMR diagnosis: Diagnosis of polymyalgia rheumatica (PMR)

Chunk 5.1

PMR steroid response: Member meets ONE of the following: (a) inadequate response to corticosteroids (e.g., prednisone) OR (b) inability to tolerate tapering of corticosteroids (e.g., prednisone).

Chunk 5.2

Continuation of Therapy

Reauthorization (all indications):

Reauthorization clinical response: Submission of medical records (e.g., chart notes) demonstrating improvement in the member's condition, evidenced by low disease activity or improvement in signs and symptoms of the condition.

Chunk 6

This medication is designated as a specialty drug and must be filled at a contracted specialty pharmacy under the pharmacy benefit for Commercial/Exchange members. Approvals are issued for 24 months. Quantity/pack limits apply: Kevzara pen 150 mg — 1 pack (2 x 150 mg pens) per 4 weeks; Kevzara pen 200 mg — 1 pack (2 x 200 mg pens) per 4 weeks.

Use of the drug without meeting the indication-specific prior therapy requirements or without documented trial and failure, contraindication, or intolerance to the specified conventional and biologic/JAK therapies is considered not to meet the authorization criteria. Examples include failure to document the required number or type of prior biologic/JAK therapies for RA or pJIA, or not documenting inadequate response or inability to taper corticosteroids for PMR. Such omissions may render the request not medically necessary under this policy.

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization (PA) is required for Commercial/Exchange members. This product is designated specialty and must be filled at a contracted specialty pharmacy.

Applies to Commercial/Exchange members
Specialty pharmacy dispensing rule: must be dispensed via contracted specialty pharmacy

Step Therapy

Therapy Trials Required

Therapy trials required: Authorization is contingent on documented trials and failures (or documented contraindication or intolerance) to specified conventional and biologic/JAK therapies per diagnosis.

RA: Trial and failure, contraindication, or intolerance to TWO of: Cimzia; Enbrel; Humira (Abbvie), Hadlima, Simlandi, Yuflyma; Rinvoq; Simponi; Xeljanz or Xeljanz XR. AND trial and failure, contraindication, or intolerance to BOTH: Tyenne and Orencia. AND minimum 3-month trial and failure, contraindication, or intolerance to ONE conventional therapy at maximally tolerated dose: Methotrexate; Leflunomide; Sulfasalazine.
pJIA: Minimum 6‑week trial and failure, intolerance, or contraindication to ONE conventional therapy at maximally tolerated dose: Leflunomide or Methotrexate. AND trial and failure, contraindication, or intolerance to TWO of: Cimzia; Enbrel; Humira (Abbvie), Hadlima, Simlandi, Yuflyma; Xeljanz; Rinvoq/Rinvoq LQ. AND trial and failure, contraindication, or intolerance to BOTH: Tyenne and Orencia.
PMR: Inadequate response to corticosteroids (e.g., prednisone) OR inability to tolerate tapering of corticosteroids.

Documentation Required

Required Documentation

Required documentation: For new members (coverage effective date ≤ 90 days), submit medical records documenting the member is currently receiving the requested drug (excluding samples or manufacturer patient assistance program supply). For continuation/reauthorization, submit medical records (e.g., chart notes) demonstrating improvement in the member's condition (low disease activity or improvement in signs/symptoms).

New members (≤ 90 days): medical records showing current treatment with requested drug (samples and manufacturer assistance program supply excluded)
Reauthorization: chart notes documenting clinical response — low disease activity or symptom improvement

Denial Risk

Denial Triggers

Denial Triggers: Requests are likely to be denied when required trials are not documented, required documentation (including medical records/chart notes) is missing, member is new to plan without proof of current treatment, or specialty pharmacy dispensing requirements are not met.

Missing documentation of required biologic/JAK or conventional therapy trials or failures
No medical records for new members to show current therapy when applicable
Failure to demonstrate clinical improvement on continuation requests
Noncompliance with specialty pharmacy dispensing rule

Revision History

2026-05-01administrative wording changeLatest

Administrative wording change to reauthorization verbiage (changed to 'submission of medical records (e.g., chart notes...)') and updated language for members new to the Plan; no clinical policy statement changes.

2025-06-01criteria update

Updated RA and pJIA criteria to include Tyenne as a preferred tocilizumab product (April P&T update implemented).

2024-01-01criteria update

Implemented updates including addition of polymyalgia rheumatica indication and changes to preferred drugs; effective 01/01/2024.

2023-11-15criteria update

Reviewed and updated for November P&T: removed TB requirement; updated preferred drugs and added Actemra and Orencia to RA requirements; added conventional therapies and PMR indication.

2020-10-09criteria update

Reviewed and updated for October P&T: updated RA criteria to include Amjevita (Nuvaila) as a preferred adalimumab product and added pJIA criteria; reauthorization criteria updated to require documentation of clinical response to therapy effective 01/01/2025 noted in later entry.

2019-02-20update

Policy updated (02/20/2019).

2018-06-01implementation

Policy implemented (06/01/2018) following review on 02/26/2018.

OpenPayer

Kevzara (sarilumab) prior authorization

Coverage Criteria for Kevzara (sarilumab)

Provider Requirements and Actions

Definitions

Background

Revision History