Tocilizumab (Actemra)

Policy ID: I-9005-004

Section: Injections

Effective Date: July 01, 2020

Revised Date: September 17, 2021

Revision Effective Date: October 01, 2021

Last Reviewed: September 21, 2021

Description

Tocilizumab (Actemra®) is a recombinant humanized anti-human interleukin 6 (IL-6) receptor monoclonal antibody that works to inhibit IL-6 mediated actions at soluble and membrane bound IL-6 receptors. Inhibiting the signaling pathway can lead to inhibition of activated T- and B-cells, lymphocytes, monocytes, and fibroblasts. Tocilizumab (Actemra) is available as a self-administered subcutaneous injection and as an intravenous infusion.

Tocilizumab (Actemra) intravenous infusion may be covered under the medical benefit; please refer to pharmacy policies for coverage of Tocilizumab (Actemra) self-administered subcutaneous injection.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.

Tocilizumab (Actemra) intravenous infusion

Tocilizumab (Actemra) intravenous infusion may be considered medically necessary and payable through the medical benefit when an individual meets the criteria for ANY ONE of the following:

Cytokine Release Syndrome (CRS)

The individual is two (2) years of age or older with chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome; and
The prescriber is a specialist in the area of the individual’s diagnosis, or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual has been tested for latent tuberculosis (TB) AND if positive the individual has begun therapy for latent TB; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

If approved, tocilizumab (Actemra) for CRS is approved for a maximum of 4 doses in one month.

Polyarticular Juvenile Idiopathic Arthritis (PJIA)

The individual has a diagnosis of moderately to severely active PJIA; and
ONE of the following:
- Information has been provided that indicates the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days; or
- The prescriber states the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed; or
- BOTH of the following:
  - ONE of the following:
    - The individual is two (2) years of age or older; or
    - The prescriber has provided information in support of using tocilizumab (Actemra) for the individual’s age; and
  - ONE of the following:
    - The individual has tried and had an inadequate response to ONE conventional agent (i.e., methotrexate, leflunomide) used in the treatment of PJIA for at least 3-months; or
    - The individual has an intolerance or hypersensitivity to ONE of the conventional agents used in the treatment of PJIA; or
    - The individual has an FDA labeled contraindication to ALL of the conventional agents used in the treatment of PJIA; or
    - The individual’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in DrugDex with 1 or 2a level of evidence, or NCCN compendium recommended use 1 or 2a for the treatment of PJIA; and
The prescriber is a specialist in the area of the individual’s diagnosis, or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual has been tested for latent tuberculosis (TB) AND if positive the individual has begun therapy for latent TB; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

Rheumatoid Arthritis (RA)

The individual has a diagnosis of moderately to severely active RA; and
ONE of the following:
- Information has been provided that indicates the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days; or
- The prescriber states the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed; or
- BOTH of the following:
  - ONE of the following:
    - The individual is eighteen (18) years of age or older; or
    - The prescriber has provided information in support of using tocilizumab (Actemra) for the individual’s age; and
  - ONE of the following:
    - The individual has tried and had an inadequate response to maximally tolerated methotrexate (e.g., titrated to 25 mg weekly) for at least 3-months; or
    - The individual has tried and had an inadequate response to another conventional agent (e.g., hydroxychloroquine, leflunomide, or sulfasalazine) used in the treatment of RA for at least 3-months; or
    - The individual has an intolerance or hypersensitivity to ONE of the following conventional agents (i.e., maximally tolerated methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine) used in the treatment of RA; or
    - The individual has an FDA labeled contraindication to ALL conventional agents (i.e., methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine) used in the treatment of RA; or
    - The individual’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in DrugDex with 1 or 2a level of evidence, or NCCN compendium recommended use 1 or 2a for the treatment of RA; and
The prescriber is a specialist in the area of the individual’s diagnosis (e.g., rheumatologist) or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual has been tested for latent tuberculosis (TB) AND if positive the individual has begun therapy for latent TB; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

Systemic Juvenile Idiopathic Arthritis (SJIA)

The individual has a diagnosis of active SJIA; and
ONE of the following:
- Information has been provided that indicates the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days; or
- The prescriber states the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed; or
- BOTH of the following:
  - ONE of the following:
    - The individual is two (2) years of age or older; or
    - The prescriber has provided information in support of using tocilizumab (Actemra) for the individual’s age; and
  - ONE of the following:
    - The individual has tried and had an inadequate response to at least ONE NSAID (e.g., ibuprofen, celecoxib) used in the treatment of SJIA for at least 1-month; or
    - The individual has an intolerance or hypersensitivity to NSAIDs used in the treatment of SJIA; or
    - The individual has an FDA labeled contraindication to NSAIDs used in the treatment of SJIA; or
    - The individual has tried and had an inadequate response to another conventional agent (i.e., methotrexate, leflunomide, systemic corticosteroids) used in the treatment of SJIA for at least 3-months; or
    - The individual has an intolerance or hypersensitivity to ONE of the conventional agents used in the treatment of SJIA; or
    - The individual has an FDA labeled contraindication to ALL of the conventional agents used in the treatment of SJIA; or
    - The individual’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in DrugDex with 1 or 2a level of evidence, or NCCN compendium recommended use 1 or 2a for the treatment of SJIA; and
The prescriber is a specialist in the area of the individual’s diagnosis, or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual has been tested for latent tuberculosis (TB) AND if positive the individual has begun therapy for latent TB; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

The use of tocilizumab (Actemra) intravenous infusion is considered experimental/investigational and, therefore, non-covered for any other indication. Scientific evidence has not established the effectiveness for any other indication.

Procedure Codes

J3262

Reauthorization Criteria

Continuation of therapy with tocilizumab (Actemra) intravenous infusion may be considered medically necessary when the following criteria are met:

The individual has been previously approved for tocilizumab (Actemra) through the Blue Cross Blue Shield of North Dakota’s precertification process; and
The individual has had clinical benefit with tocilizumab (Actemra); and
The prescriber is a specialist in the area of the individual’s diagnosis, or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

Note: Tocilizumab (Actemra) intravenous infusion for CRS should always be reviewed under the initial criteria

Tocilizumab (Actemra) intravenous infusion for any other indication is considered experimental/investigational and therefore non-covered. Scientific evidence has not established the effectiveness for any other indication.

Procedure Codes

J3262

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

D89.831	D89.832	D89.833	D89.834	D89.835	D89.839	G92.01
G92.02	G92.03	G92.04	G92.05	M05.00	M05.011	M05.012
M05.019	M05.021	M05.022	M05.029	M05.031	M05.032	M05.039
M05.041	M05.042	M05.049	M05.051	M05.052	M05.059	M05.061
M05.062	M05.069	M05.071	M05.072	M05.079	M05.09	M05.111
M05.112	M05.121	M05.122	M05.131	M05.132	M05.141	M05.142
M05.151	M05.152	M05.161	M05.162	M05.171	M05.172	M05.19
M05.20	M05.211	M05.212	M05.219	M05.221	M05.222	M05.229
M05.231	M05.232	M05.239	M05.241	M05.242	M05.249	M05.251
M05.252	M05.259	M05.261	M05.262	M05.269	M05.271	M05.272
M05.279	M05.29	M05.30	M05.311	M05.312	M05.319	M05.321
M05.322	M05.329	M05.331	M05.332	M05.339	M05.341	M05.342
M05.349	M05.351	M05.352	M05.359	M05.361	M05.362	M05.369
M05.371	M05.372	M05.379	M05.39	M05.40	M05.411	M05.412
M05.419	M05.421	M05.422	M05.429	M05.431	M05.432	M05.439
M05.441	M05.442	M05.449	M05.451	M05.452	M05.459	M05.461
M05.462	M05.469	M05.471	M05.472	M05.479	M05.49	M05.50
M05.511	M05.512	M05.519	M05.521	M05.522	M05.529	M05.531
M05.532	M05.539	M05.541	M05.542	M05.549	M05.551	M05.552
M05.559	M05.561	M05.562	M05.569	M05.571	M05.572	M05.579
M05.59	M05.60	M05.611	M05.612	M05.619	M05.621	M05.622
M05.629	M05.631	M05.632	M05.639	M05.641	M05.642	M05.649
M05.651	M05.652	M05.659	M05.661	M05.662	M05.669	M05.671
M05.672	M05.679	M05.69	M05.7A	M05.70	M05.711	M05.712
M05.719	M05.721	M05.722	M05.729	M05.731	M05.732	M05.739
M05.741	M05.742	M05.749	M05.751	M05.752	M05.759	M05.761
M05.762	M05.769	M05.771	M05.772	M05.779	M05.79	M05.8A
M05.80	M05.811	M05.812	M05.819	M05.821	M05.822	M05.829
M05.831	M05.832	M05.839	M05.841	M05.842	M05.849	M05.851
M05.852	M05.859	M05.861	M05.862	M05.869	M05.871	M05.872
M05.879	M05.89	M05.9	M06.0A	M06.00	M06.011	M06.012
M06.019	M06.021	M06.022	M06.029	M06.031	M06.032	M06.039
M06.041	M06.042	M06.049	M06.051	M06.052	M06.059	M06.061
M06.062	M06.069	M06.071	M06.072	M06.079	M06.08	M06.09
M06.1	M06.20	M06.211	M06.212	M06.219	M06.221	M06.222
M06.229	M06.231	M06.232	M06.239	M06.241	M06.242	M06.249
M06.251	M06.252	M06.259	M06.261	M06.262	M06.269	M06.271
M06.272	M06.279	M06.28	M06.29	M06.30	M06.311	M06.312
M06.319	M06.321	M06.322	M06.329	M06.331	M06.332	M06.339
M06.341	M06.342	M06.349	M06.351	M06.352	M06.359	M06.361
M06.362	M06.369	M06.371	M06.372	M06.379	M06.38	M06.39
M06.4	M06.8A	M06.80	M06.811	M06.812	M06.819	M06.821
M06.822	M06.829	M06.831	M06.832	M06.839	M06.841	M06.842
M06.849	M06.851	M06.852	M06.859	M06.861	M06.862	M06.869
M06.871	M06.872	M06.879	M06.88	M06.89	M06.9	M08.0A
M08.00	M08.011	M08.012	M08.019	M08.021	M08.022	M08.029
M08.031	M08.032	M08.039	M08.041	M08.042	M08.049	M08.051
M08.052	M08.059	M08.061	M08.062	M08.069	M08.071	M08.072
M08.079	M08.08	M08.09	M08.2A	M08.20	M08.211	M08.212
M08.219	M08.221	M08.222	M08.229	M08.231	M08.232	M08.239
M08.241	M08.242	M08.249	M08.251	M08.252	M08.259	M08.261
M08.262	M08.269	M08.271	M08.272	M08.279	M08.28	M08.29
M08.3	M08.4A	M08.40	M08.411	M08.412	M08.419	M08.421
M08.422	M08.429	M08.431	M08.432	M08.439	M08.441	M08.442
M08.449	M08.451	M08.452	M08.459	M08.461	M08.462	M08.469
M08.471	M08.472	M08.479	M08.48	M08.80	M08.811	M08.812
M08.819	M08.821	M08.822	M08.829	M08.831	M08.832	M08.839
M08.841	M08.842	M08.849	M08.851	M08.852	M08.859	M08.861
M08.862	M08.869	M08.871	M08.872	M08.879	M08.88	M08.89
M08.9A	M08.90	M08.911	M08.912	M08.919	M08.921	M08.922
M08.929	M08.931	M08.932	M08.939	M08.941	M08.942	M08.949
M08.951	M08.952	M08.959	M08.961	M08.962	M08.969	M08.971
M08.972	M08.979	M08.98	M08.99	M31.5	M31.6	M34.81
R65.10	R65.11	T45.1X5A	T45.1X5D	T45.1X5S	T80.90XA	T80.90XD
T80.90XS

Professional Statements and Societal Positions Guidelines

FDA Labeled Contraindication(s)

Individuals with known hypersensitivity to Actemra

ND Committee Review

Original Effective Date of tocilizumab (Actemra) policy: July 1, 2018

Internal Medical Policy Committee 3-16-2020 Updated preferred products effective 1-1-2020, added reauthorization criteria, added additional diagnosis codes

Internal Medical Policy Committee 7-22-2020 Updated policy number from I-31 to I-9005, separated out criteria for self-administered subcutaneous injections and intravenous infusion, 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, removed subcutaneous injection criteria from the policy, 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

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: I-9005-003

Section: Injections

Effective Date: July 01, 2020

Revised Date: March 01, 2021

Revision Effective Date: May 01, 2021

Last Reviewed: March 17, 2021

Archived Date: September 30, 2021

Description

Tocilizumab (Actemra) intravenous infusion may be covered under the medical benefit; please refer to pharmacy policies for coverage of Tocilizumab (Actemra) self-administered subcutaneous injection.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Tocilizumab (Actemra) intravenous infusion

Tocilizumab (Actemra) intravenous infusion may be considered medically necessary and payable through the medical benefit when an individual meets the criteria for ANY ONE of the following:

Cytokine Release Syndrome (CRS)

The individual is two (2) years of age or older with chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome; and
The prescriber is a specialist in the area of the individual’s diagnosis, or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual has been tested for latent tuberculosis (TB) AND if positive the individual has begun therapy for latent TB; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

If approved, tocilizumab (Actemra) for CRS is approved for a maximum of 4 doses in one month.

Polyarticular Juvenile Idiopathic Arthritis (PJIA)

The individual has a diagnosis of moderately to severely active PJIA; and
ONE of the following:
- Information has been provided that indicates the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days; or
- The prescriber states the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed; or
- BOTH of the following:
  - ONE of the following:
    - The individual is two (2) years of age or older; or
    - The prescriber has provided information in support of using tocilizumab (Actemra) for the individual’s age; and
  - ONE of the following:
    - The individual has tried and had an inadequate response to ONE conventional agent (i.e., methotrexate, leflunomide) used in the treatment of PJIA for at least 3-months; or
    - The individual has an intolerance or hypersensitivity to ONE of the conventional agents used in the treatment of PJIA; or
    - The individual has an FDA labeled contraindication to ALL of the conventional agents used in the treatment of PJIA; or
    - The individual’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in DrugDex with 1 or 2a level of evidence, or NCCN compendium recommended use 1 or 2a for the treatment of PJIA; and
The prescriber is a specialist in the area of the individual’s diagnosis, or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual has been tested for latent tuberculosis (TB) AND if positive the individual has begun therapy for latent TB; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

Rheumatoid Arthritis (RA)

The individual has a diagnosis of moderately to severely active RA; and
ONE of the following:
- Information has been provided that indicates the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days; or
- The prescriber states the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed; or
- BOTH of the following:
  - ONE of the following:
    - The individual is eighteen (18) years of age or older; or
    - The prescriber has provided information in support of using tocilizumab (Actemra) for the individual’s age; and
  - ONE of the following:
    - The individual has tried and had an inadequate response to maximally tolerated methotrexate (e.g., titrated to 25 mg weekly) for at least 3-months; or
    - The individual has tried and had an inadequate response to another conventional agent (e.g., hydroxychloroquine, leflunomide, or sulfasalazine) used in the treatment of RA for at least 3-months; or
    - The individual has an intolerance or hypersensitivity to ONE of the following conventional agents (i.e., maximally tolerated methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine) used in the treatment of RA; or
    - The individual has an FDA labeled contraindication to ALL conventional agents (i.e., methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine) used in the treatment of RA; or
    - The individual’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in DrugDex with 1 or 2a level of evidence, or NCCN compendium recommended use 1 or 2a for the treatment of RA; and
The prescriber is a specialist in the area of the individual’s diagnosis (e.g., rheumatologist) or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual has been tested for latent tuberculosis (TB) AND if positive the individual has begun therapy for latent TB; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

Systemic Juvenile Idiopathic Arthritis (SJIA)

The individual has a diagnosis of active SJIA; and
ONE of the following:
- Information has been provided that indicates the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days; or
- The prescriber states the individual has been treated with tocilizumab (Actemra) (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed; or
- BOTH of the following:
  - ONE of the following:
    - The individual is two (2) years of age or older; or
    - The prescriber has provided information in support of using tocilizumab (Actemra) for the individual’s age; and
  - ONE of the following:
    - The individual has tried and had an inadequate response to at least ONE NSAID (e.g., ibuprofen, celecoxib) used in the treatment of SJIA for at least 1-month; or
    - The individual has an intolerance or hypersensitivity to NSAIDs used in the treatment of SJIA; or
    - The individual has an FDA labeled contraindication to NSAIDs used in the treatment of SJIA; or
    - The individual has tried and had an inadequate response to another conventional agent (i.e., methotrexate, leflunomide, systemic corticosteroids) used in the treatment of SJIA for at least 3-months; or
    - The individual has an intolerance or hypersensitivity to ONE of the conventional agents used in the treatment of SJIA; or
    - The individual has an FDA labeled contraindication to ALL of the conventional agents used in the treatment of SJIA; or
    - The individual’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in DrugDex with 1 or 2a level of evidence, or NCCN compendium recommended use 1 or 2a for the treatment of SJIA; and
The prescriber is a specialist in the area of the individual’s diagnosis, or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual has been tested for latent tuberculosis (TB) AND if positive the individual has begun therapy for latent TB; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

Procedure Codes

J3262

Reauthorization Criteria

Continuation of therapy with tocilizumab (Actemra) intravenous infusion may be considered medically necessary when the following criteria are met:

The individual has been previously approved for tocilizumab (Actemra) through the Blue Cross Blue Shield of North Dakota’s precertification process; and
The individual has had clinical benefit with tocilizumab (Actemra); and
The prescriber is a specialist in the area of the individual’s diagnosis, or the prescriber has consulted with a specialist in the area of the individual’s diagnosis; and
The individual will NOT be using tocilizumab (Actemra) with another biologic immunomodulator agent or Otezla; and
The individual does NOT have any FDA labeled contraindications to tocilizumab (Actemra).

Note: Tocilizumab (Actemra) intravenous infusion for CRS should always be reviewed under the initial criteria

Procedure Codes

J3262

Diagnosis Codes

D89.831	D89.832	D89.833	D89.834	D89.835	D89.839	M05.00
M05.011	M05.012	M05.019	M05.021	M05.022	M05.029	M05.031
M05.032	M05.039	M05.041	M05.042	M05.049	M05.051	M05.052
M05.059	M05.061	M05.062	M05.069	M05.071	M05.072	M05.079
M05.09	M05.111	M05.112	M05.121	M05.122	M05.131	M05.132
M05.141	M05.142	M05.151	M05.152	M05.161	M05.162	M05.171
M05.172	M05.19	M05.20	M05.211	M05.212	M05.219	M05.221
M05.222	M05.229	M05.231	M05.232	M05.239	M05.241	M05.242
M05.249	M05.251	M05.252	M05.259	M05.261	M05.262	M05.269
M05.271	M05.272	M05.279	M05.29	M05.30	M05.311	M05.312
M05.319	M05.321	M05.322	M05.329	M05.331	M05.332	M05.339
M05.341	M05.342	M05.349	M05.351	M05.352	M05.359	M05.361
M05.362	M05.369	M05.371	M05.372	M05.379	M05.39	M05.40
M05.411	M05.412	M05.419	M05.421	M05.422	M05.429	M05.431
M05.432	M05.439	M05.441	M05.442	M05.449	M05.451	M05.452
M05.459	M05.461	M05.462	M05.469	M05.471	M05.472	M05.479
M05.49	M05.50	M05.511	M05.512	M05.519	M05.521	M05.522
M05.529	M05.531	M05.532	M05.539	M05.541	M05.542	M05.549
M05.551	M05.552	M05.559	M05.561	M05.562	M05.569	M05.571
M05.572	M05.579	M05.59	M05.60	M05.611	M05.612	M05.619
M05.621	M05.622	M05.629	M05.631	M05.632	M05.639	M05.641
M05.642	M05.649	M05.651	M05.652	M05.659	M05.661	M05.662
M05.669	M05.671	M05.672	M05.679	M05.69	M05.7A	M05.70
M05.711	M05.712	M05.719	M05.721	M05.722	M05.729	M05.731
M05.732	M05.739	M05.741	M05.742	M05.749	M05.751	M05.752
M05.759	M05.761	M05.762	M05.769	M05.771	M05.772	M05.779
M05.79	M05.8A	M05.80	M05.811	M05.812	M05.819	M05.821
M05.822	M05.829	M05.831	M05.832	M05.839	M05.841	M05.842
M05.849	M05.851	M05.852	M05.859	M05.861	M05.862	M05.869
M05.871	M05.872	M05.879	M05.89	M05.9	M06.0A	M06.00
M06.011	M06.012	M06.019	M06.021	M06.022	M06.029	M06.031
M06.032	M06.039	M06.041	M06.042	M06.049	M06.051	M06.052
M06.059	M06.061	M06.062	M06.069	M06.071	M06.072	M06.079
M06.08	M06.09	M06.1	M06.20	M06.211	M06.212	M06.219
M06.221	M06.222	M06.229	M06.231	M06.232	M06.239	M06.241
M06.242	M06.249	M06.251	M06.252	M06.259	M06.261	M06.262
M06.269	M06.271	M06.272	M06.279	M06.28	M06.29	M06.30
M06.311	M06.312	M06.319	M06.321	M06.322	M06.329	M06.331
M06.332	M06.339	M06.341	M06.342	M06.349	M06.351	M06.352
M06.359	M06.361	M06.362	M06.369	M06.371	M06.372	M06.379
M06.38	M06.39	M06.4	M06.8A	M06.80	M06.811	M06.812
M06.819	M06.821	M06.822	M06.829	M06.831	M06.832	M06.839
M06.841	M06.842	M06.849	M06.851	M06.852	M06.859	M06.861
M06.862	M06.869	M06.871	M06.872	M06.879	M06.88	M06.89
M06.9	M08.0A	M08.00	M08.011	M08.012	M08.019	M08.021
M08.022	M08.029	M08.031	M08.032	M08.039	M08.041	M08.042
M08.049	M08.051	M08.052	M08.059	M08.061	M08.062	M08.069
M08.071	M08.072	M08.079	M08.08	M08.09	M08.2A	M08.20
M08.211	M08.212	M08.219	M08.221	M08.222	M08.229	M08.231
M08.232	M08.239	M08.241	M08.242	M08.249	M08.251	M08.252
M08.259	M08.261	M08.262	M08.269	M08.271	M08.272	M08.279
M08.28	M08.29	M08.3	M08.4A	M08.40	M08.411	M08.412
M08.419	M08.421	M08.422	M08.429	M08.431	M08.432	M08.439
M08.441	M08.442	M08.449	M08.451	M08.452	M08.459	M08.461
M08.462	M08.469	M08.471	M08.472	M08.479	M08.48	M08.80
M08.811	M08.812	M08.819	M08.821	M08.822	M08.829	M08.831
M08.832	M08.839	M08.841	M08.842	M08.849	M08.851	M08.852
M08.859	M08.861	M08.862	M08.869	M08.871	M08.872	M08.879
M08.88	M08.89	M08.9A	M08.90	M08.911	M08.912	M08.919
M08.921	M08.922	M08.929	M08.931	M08.932	M08.939	M08.941
M08.942	M08.949	M08.951	M08.952	M08.959	M08.961	M08.962
M08.969	M08.971	M08.972	M08.979	M08.98	M08.99	R65.10
R65.11	T45.1X5A	T45.1X5D	T45.1X5S	T80.90XA	T80.90XD	T80.90XS

Professional Statements and Societal Positions Guidelines

FDA Labeled Contraindication(s)

Individuals with known hypersensitivity to Actemra

ND Committee Review

Original Effective Date of tocilizumab (Actemra) policy: July 1, 2018

Internal Medical Policy Committee 3-16-2020 Updated preferred products effective 1-1-2020, added reauthorization criteria, added additional diagnosis codes

Internal Medical Policy Committee 3-17-2021 Updated criteria for CRS, PJIA, RA, and SJIA and updated reauthorization criteria

Links

References (PDF)

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