1)
Actemra (Tocilizumab)
requires pre-authorization.
2)
Actemra (Tocilizumab) is
considered medically necessary to treat moderately to severely active rheumatoid
arthritis (M05.00 – M06.9) who have had an inadequate response to two (2) of
Humira, Cimzia, Simponi, Xeljanz/XR, and Rinvoq.
3)
Actemra is considered
medically necessary to treat polyarticular juvenile idiopathic arthritis or
systemic juvenile idiopathic arthritis (M08.00 – M08.48) in patients who have
had an inadequate response to Humira (Adalimumab). 4) Actemra is considered
medically necessary to treat chimeric antigen receptor (CAR) T-cell induced
severe or life-threatening cytokine release syndrome (CRS)
4)
Actemra is considered
medically necessary to treat temporal arteritis (also known as gian cell
arteritis [GCA]).
5)
The subcutaneous dosage
form is preferred. If the
intravenous dosage form is requested, documentation must be provided as to why
the subcutaneous dosage form cannot be used.
6)
Actemra has not been
studied and its use should be avoided in combination with biological DMARDs such
as TNF antagonists (Enbrel, Humira, Remicade, and Simponi), IL-1R antagonists
(Kineret), anti-CD20 monoclonal antibodies (Rituxan), and selective
co-stimulation modulators (Orencia) because of the possibility of increased
immunosuppression and increased risk of infection.
Codes Used In This BI:
J3262 -
Tocilizumab injection