Limited coverage criteria - tocilizumab for rheumatoid arthritis

 

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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
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 to 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. Coverage is limited to 800 mg every 4 weeks for the IV formulation or 162 mg once weekly for the SC formulation

Special Authority request form(s)

• HLTH 5345 – Targeted DMARDs for Rheumatoid Arthritis—Initial / Switch (PDF, 453KB)
• HLTH 5354 – Targeted DMARDs for Rheumatoid Arthritis—Renewal (PDF, 399KB)
• HLTH 5383 – Health Assessment Questionnaire (HAQ) (PDF, 528KB)