Limited Coverage Drugs - Tocilizumab for the treatment of active polyarticular Juvenile Idiopathic Arthritis

Generic Name

tocilizumab

Strength

80 mg per 4 mL, 200 mg per 10 mL, 400 mg per 20 mL
Form intravenous infusion vial

Special Authority Criteria

Approval Period

For the treatment of moderate to severe active polyarticular Juvenile Idiopathic Arthritis (pJIA) for patients 2 years of age and older, who, due to intolerance or lack of efficacy, have not adequately responded to methotrexate.

1 year

Practitioner Exemptions

  • A Collaborative Prescribing Agreement (CPA) is available to a limited number of practitioners in the following specialty: Paediatric Rheumatology.
  • Important: PharmaCare coverage is provided for tocilizumab in patients with pJIA who meet the Limited Coverage criteria and whose prescription has been written by a paediatric rheumatologist who has entered into a CPA.
  • PharmaCare coverage is subject to the patient's PharmaCare plan rules, including any annual deductible requirement.
  • Each CPA must be signed by the paediatric rheumatologist who is requesting coverage and not a delegate.
  • Paediatric rheumatologists who have not signed a CPA may submit a Special Authority request if the patient meets the Limited Coverage criteria above. In addition, a Childhood Health Assessment Questionnaire Disability Index (CHAQ-DI) and Visual Analogue Scale (VAS) documentation is required. These prescriptions will not be covered automatically.

Special Notes

  • The maximum covered allowable supply of tocilizumab is 28 days per fill.

Special Authority Request Form(s)