Limited coverage drugs – tocilizumab (for active polyarticular juvenile idiopathic arthritis)
Last updated on September 27, 2024
|
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 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 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 requests