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
