Limited Coverage Drugs - Tocilizumab for the treatment of active systemic Juvenile Idiopathic Arthritis (sJIA)

Generic Name

tocilizumab

Strength

80 mg / 4 ml, 200 mg / 10 ml, 400 mg / 20 ml
Form intravenous (IV) infusion vial

Special Authority Criteria

Approval Period

For the treatment of active systemic Juvenile Idiopathic Arthritis (sJIA) in patients two years of age and older who, due to intolerance or lack of efficacy, have not adequately responded to:

  1. non-steroidal anti-inflammatory drugs (NSAIDs)

AND

  1. systemic corticosteroid drugs (with or without methotrexate).

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.

Special Authority Request Form(s)