Coverage Policies

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Current policies effective through April 30, 2024.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

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QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 12/08/2010	Title: Actemra (Tocilizumab)
Revision Date: 01/01/2020	Document: BI285:00
CPT Code(s): J3262
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Actemra (Tocilizumab) requires pre-authorization. 2) Actemra is used to treat moderate to severe rheumatoid arthritis that has not responded to other medications, juvenile arthritis, cytokine release syndrome, and temporal arteritis. 3) Actemra is available in both an intravenous and subcutaneous dosage form. The subcutaneous dosage form should be used unless there is a specific reason it cannot be used.
Medical Statement
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
Limits
Actemra is available through our specialty pharmacy program and is limited to a maximum 30 day supply at one time.
Reference
1) Actemra Product Information. Genentech, Inc. A Member of the Roche Group 1 DNA Way South San Francisco, CA January 2010 2) Clinical Pharmacology (online). Gold Standard Elsevier. 302 Knights Run Ave., Suite 800, Tampa, FL 2010 Addendum: Effective 11/01/2017: Updated pre-requisite drugs to include 2 of Humira, Cimzia, and Simponi.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.

Coverage Policies

Important! Please note:

Addendum:

Effective 11/01/2017: Updated pre-requisite drugs to include 2 of Humira, Cimzia, and Simponi.