CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Sarilumab (Kevzara) — Coverage Criteria for Rheumatoid Arthritis and Polymyalgia Rheumatica

Covers clinical prior authorization and medical necessity requirements for sarilumab (Kevzara) in adults with moderately to severely active rheumatoid arthritis (RA) and for polymyalgia rheumatica (PMR), including required documentation, prescriber specialty, and safety screening.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySarilumab (Kevzara) — Coverage Criteria for RA and PMR

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization with documentation of required prior therapy and chart notes showing positive clinical response or justification for intolerance/contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical authorization period

within 6 monthsTB screening timing

Rheumatologistrequired prescriber

RF/anti-CCP/CRP or ESRbiomarker testing

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Therapy (RA)

Covered when ALL of the following are met for Rheumatoid Arthritis (RA):

RA initial coverage requirements: Member is an adult with moderately to severely active RA; member has had inadequate response or intolerance to one or more disease-modifying antirheumatic drugs (DMARDs); member has undergone a trial of methotrexate for at least 3 months titrated to at least 15 mg/week unless there is documented intolerance or contraindication to methotrexate; relevant biomarker testing (rheumatoid factor and/or anti-CCP, and CRP and/or ESR) is documented if applicable.at least a 3-month trial of methotrexate titrated to at least 15 mg/week

Authorization may be granted for 12 months if criteria are met.

Continuation Therapy (RA)

Covered when ALL of the following are met for continuation in RA:

RA continuation requirements: Chart notes or medical record documentation demonstrating a positive clinical response, defined as ≥20% improvement from baseline in tender joint count, swollen joint count, pain, or disability.≥20% improvement

Authorization of 12 months may be granted.

Initial Therapy (PMR)

Covered when ANY of the following are met for Polymyalgia Rheumatica (PMR):

PMR initial coverage pathways: Member has experienced an inadequate response to systemic corticosteroids; OR member experienced a disease flare during corticosteroid taper; OR member has experienced an inadequate response to methotrexate; OR member has intolerance or contraindication to both systemic corticosteroids and methotrexate.

Authorization of 12 months may be granted if criteria are met.

Continuation Therapy (PMR)

Covered when ALL of the following are met for continuation in PMR:

PMR continuation requirements: Chart notes or medical record documentation supporting a positive clinical response, evidenced by low disease activity or improvement from baseline in signs or symptoms such as morning stiffness, hip or shoulder pain, hip/shoulder range of motion, or CRP/ESR.improvement from baseline in listed signs/symptoms

Authorization of 12 months may be granted.

Not Medically Necessary / Experimental

Limitations and investigational statements:

Experimental/Investigational exclusions: Use of sarilumab for indications other than the listed FDA‑approved and compendial uses (RA and PMR as specified) is considered experimental/investigational and not medically necessary.

Do not administer sarilumab concomitantly with any other biologic or targeted synthetic disease‑modifying therapy for the same indication (see policy exclusions).

Do not administer sarilumab concomitantly with any other biologic drug or targeted synthetic drug for the same indication. This applies to all indications covered by the policy and must be followed when considering initiation or continuation of therapy.

Use of sarilumab for indications other than the FDA-approved and compendial uses listed in this policy (adult rheumatoid arthritis and adult polymyalgia rheumatica per the policy criteria) is considered experimental/investigational and not medically necessary.

Provider Actions / Authorization

Prior Authorization

Prior authorization: 12-month approvals

Authorization may be granted for up to 12 months when criteria are met.

Authorization duration: 12 months (when criteria met)
Applies to adult members, including new members

Step Therapy

Step therapy requirements

Step therapy requires a trial of methotrexate for rheumatoid arthritis unless there is documented intolerance or contraindication. A trial is defined as at least 3 months of methotrexate at adequate dosing (titrated to at least 15 mg/week) with inadequate response. If methotrexate is not advisable, provide documentation of the clinical reason to avoid therapy.

Required trial: methotrexate ≥ 3 months at adequate dosing (≥ 15 mg/week)
Exception: documented intolerance or contraindication to methotrexate

Documentation Required

Required documentation

For initial requests, submit chart notes, laboratory results, or claims history documenting prior medication trials and responses, biomarker testing (RF, anti-CCP, CRP and/or ESR) when applicable, and other relevant clinical documentation. For continuation requests, submit chart notes or medical record documentation supporting a positive clinical response (e.g., ≥20% improvement in disease activity measures for RA or improvement in PMR signs/symptoms).

Initial documentation: chart notes, lab results, claims history showing prior meds and responses; biomarker results (RF, anti-CCP, CRP/ESR) when applicable
Continuation documentation: chart notes demonstrating positive clinical response (e.g., ≥20% improvement in tender/swollen joint count, pain, or disability for RA)

Denial Risk

TB screening and active infection

Do not administer the requested medication to members with active tuberculosis (TB). A documented negative TB screening (PPD, IGRA, or chest X-ray) within 6 months is required for members naive to biologic or targeted synthetic drugs. If TB screening is positive, further testing must be done to confirm no active disease. If latent TB is identified, TB treatment must be started prior to initiation of therapy.

Negative TB test (PPD, IGRA, or chest X-ray) within 6 months for biologic/targeted synthetic–naive members
If screening positive: confirm no active TB before therapy
If latent TB: begin TB treatment prior to starting medication
Do not start therapy if active TB is present

OpenPayer

Sarilumab (Kevzara) — Coverage Criteria for Rheumatoid Arthritis and Polymyalgia Rheumatica

Coverage Criteria

Coding

Provider Actions / Authorization

Background

Definitions