Q5156, Injection, tocilizumab-anoh (avtozma), biosimilar, 1 mg
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation citing authoritative source(s) (FDA labeling, DrugDex, MCG, NCCN, peer-reviewed literature) supporting the requested therapy and dosing.
- Clinical records demonstrating that the therapy is effective for the member's specific diagnosis or procedure.
- Providers and members must consult and document the member's benefit plan, summary plan description, or contract to determine applicable exclusions, limitations, and coverage.
- Verify and document any applicable state regulations that may affect coverage.
Key Coverage Criteria
- Requested therapy is covered only when proven effective for the relevant diagnosis or procedure.
- Drug therapy is covered only when the proposed dose, frequency, and duration are consistent with recommendations in at least one authoritative source (e.g., FDA labeling, DrugDex, MCG, NCCN).
- Coverage is supported by FDA-approved labeling and/or nationally recognized authoritative references, peer-reviewed literature, or generally accepted standards of medical care.
- Coverage, exclusions, and limits for services and supplies are determined by the member's benefit plan, summary plan description, or contract.
- State regulations may affect coverage and should be checked prior to rendering services.
- Coverage of any FDA-approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U.S. Department of Health and Human Services (applies to HCSC members residing in Ohio).
7 Active Policies
BCBSIL-RX501.115, Tocilizumab and Associated Biosimilar(s)
BCBSMT-RX501.115, Tocilizumab and Associated Biosimilar(s)
BCBSNM-RX501.115, Tocilizumab and Associated Biosimilar(s)
BCBSOK-RX501.115, Tocilizumab and Associated Biosimilar(s)
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
Related Codes
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