Prior Authorization Criteria for Approval

Arcalyst will be approved when BOTH of the following are met:

1. ONE of the following:
   1. BOTH of the following: 
      1. The patient has been diagnosed with Cryopyrin-Associated Periodic Syndromes (CAPS) including Familial Cold Auto-inflammatory Syndrome (FCAS) or MuckleWells Syndrome (MWS) AND 
      2. The patient is at least 12 years of age OR 
   2. BOTH of the following: 
      1. The patient has a diagnosis of deficiency of interleukin-1 receptor antagonist AND 
      2. The requested medication is being used for maintenance of remission OR 
   3. ALL of the following: 
      1. The patient has a diagnosis of recurrent pericarditis AND 
      2. The requested medication is being used to reduce the risk of recurrence AND 
      3. The patient is at least 12 years of age AND 
2. The patient will NOT be using the requested medication in combination with another biologic medication 

Length of approval: 12 months