Limited coverage criteria – tocilizumab (for active polyarticular juvenile idiopathic arthritis)

 

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Generic name	tocilizumab
Strength & form	80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL, 162 mg/0.9 mL 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 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
• 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
• Special Authority requests must be submitted by a pediatric rheumatologist
• Each CPA must be signed by the pediatric rheumatologist who is requesting coverage and not a delegate
• Pediatric 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 a Visual Analogue Scale (VAS) documentation are 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)

• Log in to eForms
• HLTH 5328 – General Special Authority request (PDF, 656KB)