Limited coverage criteria - tocilizumab for the treatment of rheumatoid arthritis

Last updated on March 24, 2025

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Generic name	tocilizumab
Strength & form	IV: 80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL SC: 162 mg/0.9mL autoinjector pen: 162 mg/0.9 mL solution concentrate solution for intravenous (IV) infusion vials, solution in pre-filled syringes for subcutaneous (SC) injection, and autoinjector pen

Generic name

tocilizumab

Strength & form

IV: 80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL
SC: 162 mg/0.9mL
autoinjector pen: 162 mg/0.9 mL solution

concentrate solution for intravenous (IV) infusion vials, solution in pre-filled syringes for subcutaneous (SC) injection, and autoinjector pen

Special Authority criteria	Approval period
For the treatment of rheumatoid arthritis (RA) when: A Special Authority request is submitted by a rheumatologist AND Prescribed according to established criteria (as indicated on relevant Special Authority form below)	Initial: 1 year Renewal: 1 year or indefinite

Special Authority criteria

Approval period

For the treatment of rheumatoid arthritis (RA) when:

A Special Authority request is submitted by a rheumatologist

AND

Prescribed according to established criteria (as indicated on relevant Special Authority form below)

Initial: 1 year

Renewal: 1 year or indefinite

Practitioner Exemptions

None

Special Notes

PharmaCare covers a maximum of 28 days’ supply per fill for the IV formulation, and up to 56 days for the SC formulation when dosed at 14-day intervals

Special Authority request form(s)

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