J3262, Injection, tocilizumab, 1 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Procedure codes listed are for general reference and may not be all-inclusive.
- Benefit coverage/reimbursement determinations must be based on the written coverage position in the Medical Policy, not on the presence or absence of listed codes.
- Coverage determinations must include review of the member's benefit contract or SPD for coverage definitions, exclusions, and limitations (e.g., dollar or duration caps).
Key Coverage Criteria
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
- Polyarticular juvenile idiopathic arthritis: Initial therapy requires PJIA diagnosis, FDA-labeled dosing for PJIA, not in combination with a systemic targeted immunomodulator, and initial authorization up to 12 months; continuation requires prior Tocilizumab IV, documented positive response, FDA-labeled PJIA dosing, not in combination with systemic targeted immunomodulator, up to 12 months.
- Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
- Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
- This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
- Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).
20 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UHC-POL-tocilizumab, Tocilizumab (Actemra, Tofidence, & Tyenne) Injection for Intravenous Infusion
BCBSIL-RX502.061, Oncology Medications
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSIL-RX501.115, Tocilizumab and Associated Biosimilar(s)
BCBSMT-RX502.061, Oncology Medications
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.115, Tocilizumab and Associated Biosimilar(s)
BCBSNM-RX502.061, Oncology Medications
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.115, Tocilizumab and Associated Biosimilar(s)
BCBSOK-RX502.061, Oncology Medications
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.115, Tocilizumab and Associated Biosimilar(s)
UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UMR-POL-UMR-tocilizumab, Tocilizumab (Actemra, Tofidence, & Tyenne) Injection for Intravenous Infusion
SUREST-POL-SUREST-tocilizumab, Tocilizumab (Actemra, Tofidence, & Tyenne) Injection for Intravenous Infusion
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-F57DF6FC9C3C, Q1 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-6408D93491D1, Q1 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
Related Codes
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