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Limited coverage criteria – tocilizumab for neuromyelitis optica spectrum disorder

Last updated on April 1, 2026

 

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Generic name

tocilizumab

Brand name

Strength

Form
Avtozma™ 162 mg/0.9 mL pre-filled syringe
autoinjector
80 mg/ 4 mL
200 mg/10 mL
400 mg/20 mL		 solution for intravenous infusion
Tyenne® 162 mg/0.9 mL pre-filled syringe
autoinjector
80 mg/ 4 mL
200 mg/10 mL
400 mg/20 mL		 solution for intravenous infusion

Special Authority criteria

Approval period

Initial

For the treatment of neuromyelitis optica spectrum disorder (NMOSD), when a Special Authority request is submitted 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

1 year

Renewal

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

AND

Special Authority request is submitted by a neurologist with expertise in the diagnosis and management of NMOSD

 1 year

Practitioner exemptions

  • None

Special notes

  • 1First line treatment for NMOSD may include azathioprine or rituximab
  • Treatment with tocilizumab should be 8 mg/kg IV every 4 weeks (to a maximum dose of 800 mg) or 162 mg subcutaneously every 1 to 2 weeks
  • PharmaCare covers a maximum of 28 days' supply per fill for the IV formulation, and up to 56 days' supply for the SC formulary when dosed at 14-day intervals. Coverage is limited to 800 mg every 4 weeks for the IV formulation or 162 mg once weekly for the SC formulation
  • Tocilizumab should not be initiated during an NMOSD relapse episode
  • Tocilizumab must not be used in combination with other anti-IL-6, B-cell depletion, or complement inhibitor therapies

Special Authority request form(s)