Limited Coverage Drugs - tocilizumab for the treatment of rheumatoid arthritis

Last updated on December 3, 2020

Generic Name	tocilizumab
Strength	IV: 80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL SC: 162 mg/0.9mL autoinjector pen: 162 mg/0.9 mL solution
Form	concentrate solution for intravenous (IV) infusion vials, solution in pre-filled syringes for subcutaneous (SC) injection, and autoinjector pen

Special Authority Criteria	Approval Period
For the treatment of rheumatoid arthritis (RA) when: prescribed by a rheumatologist AND prescribed according to established criteria (as indicated on the relevant Special Authority form below).	First approval: 1 year Renewal: 1 year or indefinite

Special Authority Criteria

Approval Period

For the treatment of rheumatoid arthritis (RA) when:

prescribed by a rheumatologist

AND

prescribed according to established criteria (as indicated on the relevant Special Authority form below).

First approval: 1 year

Renewal: 1 year or indefinite

Practitioner Exemptions

None

Special Notes

PharmaCare covers a maximum of 28 days’ supply per fill for the IV formulation, and up to 56 days for the SC formulation when dosed at 14-day intervals

Special Authority Request Form(s)

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Limited Coverage Drugs - tocilizumab for the treatment of rheumatoid arthritis

Practitioner Exemptions

Special Notes

Special Authority Request Form(s)