Tocilizumab (Actemra)

Actemra (tocilizumab) is covered for specified non‑oncology indications — rheumatoid arthritis, polyarticular and systemic juvenile idiopathic arthritis, giant cell arteritis — and select off‑label compendial uses (Still’s disease, polymyalgia rheumatica, checkpoint‑inhibitor–related inflammatory arthritis, and COVID‑19 cytokine release syndrome); oncology uses and non‑FDA/non‑compendial indications are excluded. Coverage requires indication‑specific prior therapy trials (e.g., RA: 3‑month trial of ≥1 biologic or conventional DMARD; other indications: specified trials of corticosteroids, NSAIDs or alternative agents), prescription or consultation by a rheumatologist (or oncologist for checkpoint‑related arthritis), adherence to weight‑based dosing/frequency and safety criteria, documentation of diagnosis and prior trials, and demonstrated therapeutic response for reauthorization (with labs as applicable).

"Rheumatoid arthritis (RA)"