Limited Coverage Drugs - Tocilizumab for the treatment of Rheumatoid Arthritis

Generic Name                                   

tocilizumab


Strength

IV—80 mg / 4mL, 200 mg / 10 mL, 400 mg / 20 mL

SC—162 mg / 0.9 mL
Form intravenous (IV) infusion vials and subcutaneous (SC) injection solution

Special Authority Criteria

Approval Period

For the treatment of Rheumatoid Arthritis (RA) according to established criteria described in Special Authority Request forms 5345 (Initial/Switch) and 5354 (Renewal), below.

Coverage of tocilizumab for the treatment of RA is available only when tocilizumab is prescribed by a rheumatologist.

 

 

1 year

Practitioner Exemptions

  • None

Special Notes

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

Special Authority Request Form(s)