Anthem IL-6 Inhibitor Coverage Update

Coverage Criteria for IL-6 Inhibitors

Initial Therapy - Tocilizumab products

Covered when ALL of the following per listed indication are met (grouped by indication below).

Giant cell arteritis (Actemra and biosimilars): A. Individual is 18 years of age or older with GCA; AND B. Tocilizumab is used in combination with a tapering course of corticosteroids (such as prednisone) OR C. Tocilizumab is used as a single agent following discontinuation of corticosteroids

Rheumatoid arthritis (Actemra and biosimilars): A. Individual is 18 years of age or older with moderate to severe RA; AND B. Individual has had an inadequate response to methotrexate titrated to maximally tolerated dose (ACR 2021) OR C. If methotrexate is not tolerated, individual has had an inadequate response to, or is intolerant of other conventional therapy (sulfasalazine, leflunomide, or hydroxychloroquine) OR D. Individual has a contraindication to methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine

Polyarticular juvenile idiopathic arthritis (PJIA): A. Individual is 2 years of age or older with moderate to severe PJIA; AND B. Individual has had an inadequate response to, or is intolerant of conventional therapy (nonbiologic DMARDs such as methotrexate) OR C. Individual has a contraindication to methotrexate

Still's disease (AOSD or SJIA): A. Individual is 2 years of age or older with Still's Disease as either AOSD or SJIA

Unicentric Castleman Disease: A. Diagnosis of relapsed/refractory or progressive unicentric Castleman Disease; AND B. Used as a single agent; AND C. Human immunodeficiency virus (HIV) negative; AND D. Human herpesvirus-8 (HHV-8) negative

Cytokine Release Syndrome (CRS): A. Individual is 2 years of age or older with autologous T cell immunotherapy-related CRS OR B. Individual has acute lymphocytic leukemia and is using tocilizumab for severe blinatumomab-induced CRS OR C. Individual is using tocilizumab as prophylaxis prior to first dose of any bispecific antibody to reduce risk of CRS

Chronic Antibody-Mediated Renal Transplant Rejection (cAMR): A. Chronic active antibody-mediated rejection plus donor-specific antibodies and transplant glomerulopathy; AND B. Individual has failed to respond to intravenous immune globulin (IVIG) plus rituximab therapy (with or without plasma exchange)

Systemic Sclerosis-Associated Interstitial Lung Disease (SSc-ILD): A. Diagnosis of SSc-ILD; AND B. HRCT showing ground glass opacification or fibrosis; AND C. Pulmonary function tests demonstrating Forced Vital Capacity (FVC) > 55% predicted

COVID-19 (hospitalized): A. Individual is 2 years of age or older; AND B. Individual is currently hospitalized with COVID-19; AND C. Individual is currently receiving systemic corticosteroids and requires supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO)

Acute Graft-versus-host disease (GVHD): A. Steroid-refractory acute GVHD; AND B. Initiating tocilizumab in combination with systemic corticosteroids

Immunotherapy-related toxicities: A. Individual is undergoing immune checkpoint inhibitor therapy for a cancer diagnosis; AND B. Using tocilizumab for one of: giant cell arteritis, moderate to severe inflammatory arthritis unresponsive to corticosteroids or nonbiologic DMARDs, or steroid-refractory polymyalgia rheumatica (NCCN 2A)

Other indicated conditions: Refractory/progressive KSHV-associated Inflammatory Cytokine Syndrome (KICS) (NCCN 2A); Multicentric Castleman disease progressing after prior therapy (NCCN 2A)

Initial and continuation therapy - Kevzara

Covered when ALL of the following are met for rheumatoid arthritis or other specified indications.

Rheumatoid arthritis (Kevzara): A. Individual is 18 years of age or older with moderately to severe RA; AND B. Individual has had an inadequate response to methotrexate titrated to maximally tolerated dose (ACR 2021) OR C. If methotrexate is not tolerated, individual has had an inadequate response to, or is intolerant of other conventional therapy (sulfasalazine, leflunomide, or hydroxychloroquine) OR D. Individual has a contraindication to methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine

Continuation (Kevzara): I. Individual has been receiving and is maintained on a stable dose of Kevzara (sarilumab); AND II. There is clinically significant improvement or stabilization in clinical signs and symptoms of disease

Continuation Therapy - Tocilizumab products

Continuation requests may be approved when ALL of the following are met.

Continuation (Actemra and biosimilars): I. Individual has been receiving and is maintained on a stable dose of Actemra, Avtozma, Tofidence, or Tyenne; AND II. There is clinically significant improvement or stabilization in clinical signs and symptoms of disease

Coverage conditions and quantity limits

Covered when product-specific and indication-specific clinical criteria and member benefit provisions are met; COVID-19 HCPCS codes require hospitalized patients receiving systemic corticosteroids and requiring supplemental oxygen or higher-level respiratory support.

Tocilizumab COVID-19 hospitalization requirement: HCPCS M0233-M0249 and Q0235-Q0249 apply only for hospitalized patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMOhospitalized + systemic corticosteroids + oxygen/ventilation/ECMO

See HCPCS code descriptions for product-specific assignment

Quantity limit for subcutaneous tocilizumab products: Subcutaneous tocilizumab autoinjector or prefilled syringe (Actemra, Avtozma, Tyenne) limited to 4 autoinjectors or syringes per 28 days<=4 devices per 28 days

Specific to 162 mg/0.9 mL presentations

Quantity limit for sarilumab (Kevzara):

Requests for IL-6 receptor monoclonal antibodies used in combination with certain other immunomodulatory therapies are not approved. Specifically, use of IL-6 inhibitors in combination with topical or oral JAK inhibitors, ozanimod, etrasimod, deucravacitinib, nintedanib, or the listed biologic immunomodulators (including but not limited to TNF antagonists, IL-23 inhibitors, IL-17 inhibitors, vedolizumab, ustekinumab, abatacept, IL-1 inhibitors, other IL-6 inhibitors, rituximab, or natalizumab) is not approved and will not meet coverage criteria.

Recent policy revisions updated the exclusion and combination lists. The 02/20/2026 document history notes removal of pirfenidone from the prohibited combination list and removal of selected exclusions (for example, tuberculosis and other select exclusions). The history also documents coding updates to HCPCS assignments for tocilizumab biosimilars and Tyenne effective on the dates indicated.

Requests that do not satisfy the indication-specific medical necessity criteria described elsewhere in this policy, or requests that propose combining IL-6 inhibitors with the prohibited agents listed above, will not be approved and are considered not medically necessary.

The lists of procedure, diagnosis, and device codes included in this policy are provided for informational purposes only. Inclusion or exclusion of a code does not by itself guarantee coverage; determination of coverage and reimbursement depends on the member's contract benefits and applicable prior authorization decisions at the time of service.

Coding, Dosing and Quantity Limits

Quantity limits by product and formulationmixedCovered

Actemra (tocilizumab) IV vials 80 mg, 200 mg, 400 mg	Limit = 8 mg/kg as frequently as every 4 weeks
Avtozma (tocilizumab-anoh) IV vials 80 mg, 200 mg, 400 mg	Limit = 8 mg/kg as frequently as every 4 weeks
Tofidence (tocilizumab-bavi) IV vials 80 mg, 200 mg, 400 mg	Limit = 8 mg/kg as frequently as every 4 weeks
Tyenne (tocilizumab-aazg) IV vials 80 mg, 200 mg, 400 mg	Limit = 8 mg/kg as frequently as every 4 weeks
Actemra 162 mg/0.9 mL autoinjector or prefilled syringe	Limit = 4 autoinjectors or syringes per 28 days
Avtozma 162 mg/0.9 mL autoinjector or prefilled syringe	Limit = 4 autoinjectors or syringes per 28 days
Tyenne 162 mg/0.9 mL autoinjector or prefilled syringe	Limit = 4 autoinjectors or syringes per 28 days
Kevzara (sarilumab) 150 mg, 200 mg prefilled pen/syringe	Limit = 2 pens/syringes per 28 days

Tocilizumab Agents - J/Q codesHCPCSCovered

J3262	Injection, tocilizumab, 1 mg [Actemra subcutaneous (tocilizumab)]
J3590	Unclassified biologics [when specified as Actemra subcutaneous (tocilizumab)]
Q5133	Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mg
Q5135	Injection, tocilizumab-aazg (Tyenne), biosimilar, 1 mg
Q5156	Injection, tocilizumab-anoh (Avtozma), biosimilar, 1 mg

Kevzara HCPCSHCPCS

C9399	Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) [when specified as Kevzara (sarilumab)]
J3590	Unclassified biologics [when specified as Kevzara (sarilumab)]

Tocilizumab COVID-19 specific HCPCSHCPCSCovered

M0233	Intravenous infusion, tocilizumab-aazg, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMO, includes
M0234	Intravenous infusion, tocilizumab-aazg, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMO, includes
M0235	Intravenous infusion, monoclonal antibody products with an indication for post-exposure prophylaxis or treatment of COVID-19 ... first dose [when specified as Tofidence (tocilizumab-bavi)]
M0236	Intravenous infusion, monoclonal antibody products ... second dose
M0237	Intravenous infusion, tocilizumab-anoh, for hospitalized adult patients with COVID-19 ... includes
M0238	Intravenous infusion, tocilizumab-anoh, for hospitalized adult patients with COVID-19 ... includes
M0249	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMO only, includes infusion and post administration monitoring
M0250	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years and older) with COVID-19 ... second dose [Actemra IV 2nd dose administration]
Q0235	Injection, monoclonal antibody products with an indication of post-exposure prophylaxis or treatment of COVID-19 ... 1 mg [when specified as Tofidence (tocilizumab-bavi)]
Q0237	Injection, tocilizumab-anoh, for hospitalized adult patients with COVID-19 ... 1 mg [Avtozma]

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ICD-10 Diagnoses associated with coverageICD-10

J12.82	Pneumonia due to coronavirus disease 2019
U07.1	COVID-19
M05.00-M05.A	Rheumatoid arthritis with rheumatoid factor
M06.00-M06.09	Rheumatoid arthritis without rheumatoid factor
M06.4	Inflammatory polyarthropathy
M06.80-M06.89	Other specified rheumatoid arthritis
M06.9	Rheumatoid arthritis, unspecified
M08.00-M08.9A	Juvenile arthritis
M31.5	Giant cell arteritis with polymyalgia rheumatica
M31.6	Other giant cell arteritis

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CPT copyright noticemixed

American Medical Association copyright statement for CPT

IV dosing maximum per dose

IV dosing maximum per doseUp to 8 mg/kg per dose (weight‑based IV dosing). Dose caps apply: for rheumatoid arthritis, cytokine release syndrome, and COVID‑19 each dose should not exceed 800 mg total; for giant cell arteritis each dose should not exceed 600 mg total. Indication‑specific overrides exist for pediatric JIA and CRS as described in override criteria (higher mg/kg and dosing frequency).

PJIA overrideMay approve up to 10 mg/kg every 4 weeks for individuals weighing <30 kg.

SJIA overrideMay approve up to 12 mg/kg every 2 weeks for patients <30 kg and up to 8 mg/kg every 2 weeks for patients ≥30 kg.

CRS dosing allowanceFor CRS, may approve up to four IV doses (each up to 8 mg/kg if ≥30 kg or up to 12 mg/kg if <30 kg) given at least 8 hours apart.

COVID‑19 dosing allowance

Prior Authorization, Documentation and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization required per indication — Prior authorization is required for initial and continuation requests. Approvals are granted only when indication‑specific clinical criteria (including age, diagnosis, prior therapies, and objective testing where applicable) are met. Coverage is contingent on the member's contract and benefit limitations; inclusion of a code in this policy does not guarantee member coverage.

Prior authorization required for all indications listed unless otherwise specified in the member’s benefit plan.
Approvals granted when indication‑specific criteria in the policy are documented and met.
Inclusion of a procedure, diagnosis or device code in this document is informational and does not determine member coverage — verify member benefits prior to authorization.

Step Therapy

Guideline‑Directed Step Therapy and Prior Therapy Documentation

Guideline‑directed step therapy and prior therapy documentation — Therapy decisions should follow guideline recommendations (for example, ACR guidance for rheumatoid arthritis: DMARD monotherapy with methotrexate titrated to maximally tolerated dose prior to biologic or JAK inhibitor use). Providers must document prior therapies, intolerance, contraindications, or inadequate response as required for the specific indication.

Background and Clinical Context

Interleukin-6 receptor monoclonal antibodies act by inhibiting IL-6 signaling and are used to treat multiple inflammatory and immune-mediated conditions. These agents are approved for disorders including rheumatoid arthritis, giant cell arteritis, various juvenile idiopathic arthritis subtypes (including systemic and polyarticular forms), and cytokine release syndrome, and are also used in select refractory conditions such as systemic sclerosis–associated interstitial lung disease (SSc-ILD) and chronic antibody-mediated renal transplant rejection where standard therapies have failed. Some indications have conditional or limited supporting evidence and require documentation of prior therapies or specific diagnostic testing (for example, HRCT and PFTs for SSc-ILD).

Definitions and Disease Descriptions

Systemic juvenile idiopathic arthritis (SJIA)

DefinitionSystemic juvenile idiopathic arthritis (SJIA) is an autoinflammatory condition marked by intermittent fever, rash, and arthritis.

Guideline treatment optionsACR guidance: initial therapy may include NSAIDs or glucocorticoids; IL‑1 inhibitors (anakinra or canakinumab) or tocilizumab are conditionally recommended and may be used for inadequate response or intolerance to initial therapy.

Age considerationsSJIA recommendations and dosing considerations apply to pediatric patients; overrides for tocilizumab dosing in SJIA are specified for patients <30 kg.

Giant cell arteritis (GCA)

DefinitionGiant cell arteritis (GCA) is vasculitis of large‑ and medium‑sized vessels occurring primarily in individuals >50 years of age and is commonly associated with polymyalgia rheumatica.

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Monoclonal Antibodies to Interleukin-6

Coverage Criteria for IL-6 Inhibitors

Coding, Dosing and Quantity Limits

Prior Authorization, Documentation and Provider Responsibilities

Background and Clinical Context

Definitions and Disease Descriptions