ND Committee Review
Original Effective Date of tocilizumab (Actemra) policy: July 1, 2018
Internal Medical Policy Committee 3-16-2020 -
Effective January 01, 2020
- Updated
preferred products, and
- Removed
tuberculosis (TB) criteria and made a Note
- Added
additional Diagnosis codes
Internal Medical Policy Committee 7-22-2020
- Updated
policy number from I-31 to I-9005,
and
- Separated
out criteria for self-administered subcutaneous injections and intravenous infusion,
and
- Updated
preferred products in subcutaneous injections,
and
- Removed
preferred products from intravenous infusion
Internal Medical Policy Committee 9-21-2020
- Added
language that self-administered tocilizumab (Actemra) subcutaneous injection will be reviewed under pharmacy policies,
and
- Removed
subcutaneous injection criteria from the policy,
and
- Updated
Diagnosis codes
Internal Medical Policy Committee 3-17-2021
- Updated
criteria for CRS, PJIA, RA, and SJIA
and
- Updated
reauthorization criteria
Internal Medical Policy Committee 9-21-2021
- Added
additional diagnosis codes G92.01, G92.02, G92.03, G92.04 and G92.05
Internal Medical Policy Committee 9-28-2022 Annual review, no clinical content change
Internal Medical Policy Committee 11-29-2022 -
Effective January 01, 2023
- Added
criteria for giant cell arteritis (GCA),
and
- Updated
combination therapy criteria,
and
- Removed
latent tuberculosis criteria from the policy,
and
- Removed
FDA labeled contraindications criteria from the policy;
and
- Added
Agents NOT to be used Concomitantly list,
and
- Updated
experimental/investigational statement
Internal Medical Policy Committee 11-15-2023
Effective January 01, 2024
- Added
biosimilar
tocilizumab-bavi (Tofidence)
- Removed
Systemic Juvenile Idiopathic Arthritis (SJIA) specific criteria
- Added
Other criteria
- Updated
Agents NOT to be used Concomitantly list
Internal Medical Policy Committee 3-19-2024
Effective April 01, 2024
- Added
new code, Q5133, to the policy
Internal Medical Policy Committee 9-17-2024
Effective October 01, 2024
- Added
tocilizumab-aazg (Tyenne), Q5135 to the policy
Internal Medical Policy Committee 11-19-2024
Effective December 08, 2024