Limited coverage drugs – tocilizumab (for neuromyelitis optica spectrum disorder)

tocilizumab

80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL, 162 mg/0.9 mL

Intravenous infusion vial, pre-filled syringe, autoinjector

Initial:

For the treatment of Neuromyelitis Optica Spectrum Disorder (NMOSD) and when requested by a neurologist with expertise in the diagnosis and management of NMOSD in patients with:

• Severe first attack (e.g., marked change in neurological functioning, requiring hospitalization or plasma exchange) or high disability with first attack (e.g., bilateral, or significant visual acuity loss worse than 6/60 or Expanded Disability Status Scale (EDSS) 5 at attack nadir)

OR

• The patient must have had treatment failure resulting in at least one moderate to severe relapse of NMOSD within the previous 12 months despite a trial of optimally dosed first-line therapy¹, or a documented intolerance or contraindication to a first-line therapy

12 months

Renewal:

• Patient has maintained an EDSS score of less than 8 points taken within the 3-month period immediately preceding the renewal request

AND

• When coverage is requested by a neurologist with expertise in the diagnosis and management of NMOSD