Tocilizumab (Actemra®)

Covered for specified FDA‑approved non‑oncology indications (RA, pJIA, sJIA, GCA, systemic sclerosis–associated ILD) and select compendial off‑label uses (Still’s disease, PMR, checkpoint‑inhibitor inflammatory arthritis, COVID‑19 cytokine release syndrome); uses outside these approved or compendial indications are excluded. Key requirements include indication‑specific prior therapy trials and prescriber specialty (e.g., rheumatologist, pulmonologist, or oncologist as applicable), adherence to dosing/age/lab/imaging and FVC limits (ILD requires age ≥18, CRP ≥6 mg/mL or ESR ≥28 mm/h or platelets ≥330×10^9/L, HRCT confirmation, and FVC >55% predicted), and reauthorization generally after ≥6 months with documented objective or symptomatic improvement.

"Rheumatoid arthritis (RA)"

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