Tocilizumab (Actemra)

Actemra (tocilizumab IV) is covered for FDA‑approved non‑oncology indications—adult moderate‑to‑severe rheumatoid arthritis, polyarticular and systemic juvenile idiopathic arthritis (≥2 years old)—and the compendial off‑label use Still’s disease; other/unlisted indications are not covered. Coverage requires indication‑specific prior‑therapy trials (RA: 3‑month trial of ≥1 biologic or ≥1 conventional DMARD; pJIA: trial of ≥1 other agent or start concurrently with methotrexate/leflunomide/sulfasalazine or documented contraindication; sJIA: trial of ≥1 systemic agent or ≥1 month NSAID; Still’s: 2‑month csDMARD trial and a corticosteroid trial), prescription by or consultation with a rheumatologist, documentation of diagnosis/age/weight and contraindications as applicable, initial approvals of 3 months (RA/sJIA/Still’s) or 4 months (pJIA) and 12‑month renewals contingent on documented clinical response.

"Actemra is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic ..."