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

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 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

  • PharmaCare covers a maximum of 28 days’ supply per fill for the IV formulation, and up to 84 days for the SC formulation when dosed at 21-day intervals.

Special Authority Request Form(s)