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

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, autoinjector

Special Authority criteria

Approval period

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
 12 months

Practitioner exemptions

  • None

Special notes

  • 1First line treatment for NMOSD may include azathioprine or rituximab.
  • Initial treatment with tocilizumab should be 8 mg/kg every 4 weeks, to a maximum dose of 800 mg.
  • Tocilizumab should not be initiated during a NMOSD relapse episode.
  • Tocilizumab must not be used in combination with other anti-IL-6, B-cell depletion, or complement inhibitor therapies.

Special Authority requests