Limited coverage drugs – tocilizumab (for active systemic juvenile idiopathic arthritis)
Last updated on October 18, 2022
|
Generic name |
tocilizumab |
|---|---|
|
Strength |
80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL, 162 mg/0.9 mL |
|
Form |
intravenous infusion vial, pre-filled syringe |
|
Special Authority criteria |
Approval period |
|---|---|
|
For the treatment of active systemic juvenile idiopathic arthritis (sJIA) in patients 2 years and older who, due to intolerance or lack of efficacy, have not adequately responded to
AND
|
1 year |
Practitioner exemptions
- A Collaborative Prescribing Agreement (CPA) is available to a limited number of practitioners in the following specialty: pediatric rheumatology
- Important: PharmaCare coverage covers tocilizumab for patients who meet the Limited Coverage criteria and whose prescription has been written by a pediatric 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 pediatric rheumatologist who is requesting coverage and not a delegate.
- Practitioners who have not signed a CPA may submit a Special Authority request if the patient meets the criteria above. These prescriptions will not be covered automatically.
Special notes
- For rheumatologists who have not signed a CPA, a Special Authority Request form is required, in addition to a Childhood Health Assessment Questionnaire Disability Index (CHAQ-DI) and Visual Analogue Scale (VAS) documentation.
- The maximum covered allowable supply of tocilizumab is 28 days per fill for the IV formulation, and up to 56 days for the SC formulation when dosed at 14-day intervals.
Special Authority requests