Actemra® (tocolizumab)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Commercial plans

  • Group commercial HMO, EPO, POS and PPO plans
  • Individual commercial ACA-compatible MyPriority® HMO, POS and PPO plans

Code(s): J3262

Benefit: Medical

Notes: Treatment of rheumatoid arthritis

Criteria for coverage: See PA forms

Medicaid plans

Not covered

Medicare Advantage plans

Codes: Must use CPT code outlined in the CMS local coverage determination (LCD) available at www.cms.gov.

Benefit: Part B

Notes: No authorization required; covered only when billed with the following ICD-10 diagnoses:

  • M05.60 – M05.69, Rheumatoid arthritis with involvement of other organs and systems
  • M05.70 – M05.79, Rheumatoid arthritis with or w/o involvement of other organs and systems
  • M06.00 – M06.09, Rheumatoid arthritis without rheumatoid factor
  • M06.9, Rheumatoid arthritis, unspecified
  • M08.20 – M08.29, Juvenile rheumatoid arthritis with systemic onset
  • M08.4, Pauciarticular juvenile rheumatoid arthritis