Canakinumab (Ilaris®)

Before October 31, 2026: Billing team must prepare for implementation of new Canakinumab (Ilaris®) prior authorization workflow. SPECIFIC ACTIONS: (1) Update billing system to require prior authorization for all Canakinumab claims with the specific coverage criteria outlined (periodic fever syndromes requiring flare history and inflammatory markers; Still's disease requiring biologic history; gout/pseudogout requiring 3+ flares in 12 months and failure of NSAIDs/colchicine/corticosteroids). (2) Create authorization templates requiring documentation of: diagnosis, flare frequency within specified timeframes, PGA scores or CRP levels (>10 mg/L), prior medication trials, and TB screening results. (3) Implement age verification rules in system (CAPS age ≥4 years, sJIA/AOSD age ≥2 years, gout/pseudogout age ≥18 years). (4) Flag claims with concurrent biologic/targeted synthetic drugs for automatic denial per policy restriction. (5) Train billing and prior auth staff on specialty prescriber requirements (rheumatologist or immunologist for fever syndromes/FMF; rheumatologist for sJIA/AOSD/gout). (6) Update provider encounter forms with TB screening documentation requirements. (7) Set dosing quantity limits in pharmacy system (CAPS: 150mg every 8 weeks ≥41kg; 2-3mg/kg every 8 weeks <41kg; Gout/Pseudogout: 150mg single dose, repeat ≥12 weeks). DEADLINE: Complete all system updates and staff training by October 30, 2026. CONSEQUENCES: Claims submitted without proper prior authorization and documentation will be denied; claims with missing TB screening documentation will be denied; concomitant biologic use will result in denial.