Pharmacy Prior Authorization Criteria

Sylvant (siltuximab)

Indications for Prior Authorization

Sylvant (siltuximab)

• For diagnosis of Multicentric Castleman's Disease
  Indicated for the treatment of patients with multicentric Castleman’s disease (MCD) who are human immunodeficiency virus (HIV) negative and human herpesvirus-8 (HHV-8) negative.

  Limitation of use: Sylvant was not studied in patients with MCD who are HIV positive or HHV-8 positive because Sylvant did not bind to virally produced IL-6 in a nonclinical study.

Criteria

Sylvant

Prior Authorization (Initial Authorization)

Length of Approval: 6 Months [A]

• Diagnosis of multicentric Castleman’s disease (MCD)
AND
• Patient is human immunodeficiency virus (HIV) negative
• Patient is human herpesvirus-8 (HHV-8) negative
AND
• Patient is human herpesvirus-8 (HHV-8) negative

Sylvant

Prior Authorization (Reauthorization)

Length of Approval: 6 Months [A]

• Patient demonstrates positive clinical response to therapy
AND
• Patient is human immunodeficiency virus (HIV) negative
AND
• Patient is human herpesvirus-8 (HHV-8) negative

P & T Revisions

2024-07-03, 2023-07-05, 2022-07-06, 2021-06-30

References

1. Sylvant Prescribing Information. Janssen Biotech, Inc. Horsham PA. April 2022.
2. Per clinical consult with hematologist/oncologist, June 5, 2014.

---

Revision History

• 2024-07-03: 2024 Annual Review. Updated reauthorization criteria to standard reauthorization language.
• 2023-07-05: Annual review, removed specialist requirement
• 2022-07-06: Annual review, no criteria changes.
• 2021-06-30: Annual review

---