CurrentAvMedPolicy N/A

Prior authorization and step-edit criteria for subcutaneous tocilizumab (Actemra, Tyenne) — Giant Cell Arteritis

Defines prior authorization and step-edit requirements for subcutaneous tocilizumab products (Actemra, Tyenne) for treatment of Giant Cell Arteritis in AvMed members; applies to prescribing providers requesting pharmacy-covered SQ tocilizumab.

Policy Summary

PayerAvMed

PolicySubcutaneous tocilizumab prior authorization for Giant Cell Arteritis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed, signed prior authorization form with member and prescriber information plus supporting documentation (labs, imaging, chart notes) to verify clinical criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moInitial authorization duration

12 moReauthorization duration

162 mg/wkRecommended SQ dosage

>=18Minimum age

Coverage Criteria for SQ Tocilizumab (GCA)

inv-01: Initial authorization criteria

Covered when ALL of the following are met:

Prescriber specialty: Prescribed by or in consultation with a Neurologist, Ophthalmologist, or Rheumatologist

Prescriber must sign form; supporting documentation required

Diagnosis verification: Member has diagnosis of Giant Cell Arteritis (GCA) with large vessel arteritis verified at some point by biopsy or vascular imaging (e.g., color Doppler ultrasound, MRI, PET-CT, or CT angiography)

Provide supporting biopsy or imaging reports

Age: Member is at least 18 years of age>=18 years

Policy Summary

PayerAvMed

PolicySubcutaneous tocilizumab prior authorization for Giant Cell Arteritis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed, signed prior authorization form with member and prescriber information plus supporting documentation (labs, imaging, chart notes) to verify clinical criteria.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Submission and Authorization Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for subcutaneous (SQ) tocilizumab products for Giant Cell Arteritis (GCA). Complete and legible submission is required — incomplete, incorrect, or illegible information may delay or deny the authorization.

PA required for SQ tocilizumab products (e.g., Actemra® SQ, Tyenne® SQ).
Fax completed form to 1-305-671-0200 with prescriber signature (preprinted stamps not valid).
Initial and reauthorization requests are for 12 months.
Samples do not meet step-edit/prior authorization criteria; therapy initiated with samples is not eligible.

Documentation Required

Required Submission Information

All required documentation listed on the PA form must be provided. Missing clinical information or supporting documentation (labs, imaging, chart notes) may result in denial or processing delays.

Provide member demographics (name, AvMed #, DOB) and prescriber details (name, signature, NPI, office contact, phone, fax).
Include drug details: name, formulation/strength, dosing schedule, length of therapy, weight (if applicable) and date weight obtained.
Support each checked clinical criterion with corresponding documentation (biopsy or imaging confirming large vessel arteritis, evidence of trial of systemic corticosteroid, documentation of disease response for reauthorization such as symptom improvement and inflammatory markers).
Previous therapies may be verified via pharmacy paid claims or submitted chart notes.

Denial Risk

Incomplete or Insufficient Documentation May Delay or Deny

Authorization requires prescriber specialty involvement and documentation of prior therapies and response. Failure to document specialty prescriber/consultation, age, diagnosis verification, prior corticosteroid trial, or treatment response for reauthorization can lead to denial.

Initial requests must be prescribed by or in consultation with a neurologist, ophthalmologist, or rheumatologist.
Member must be ≥18 years of age.
Diagnosis of GCA with large vessel arteritis must be verified at some point by biopsy or imaging (CDUS, MRI, PET-CT, CT angiography).
Member must have tried one systemic corticosteroid prior to approval.
For reauthorization, provide documentation of clinical improvement (signs/symptoms, ESR/CRP, and/or imaging).

Step Therapy

Step-Edit / Sample Restriction

Step-edit: use of samples to initiate therapy does not satisfy step-edit or prior authorization requirements.

Therapy initiated with samples will not be approved in lieu of documented prior therapy or meeting step criteria.

Background

Giant Cell Arteritis (GCA) is an inflammatory large-vessel vasculitis frequently managed with systemic corticosteroids. Subcutaneous tocilizumab is used in combination with a tapering course of glucocorticoids to induce and maintain disease control in GCA. For this policy, coverage is limited to members with GCA involving large vessels that has been verified by biopsy or vascular imaging (for example, color Doppler ultrasound, MRI, PET-CT, or CT angiography). The recommended subcutaneous dosing for GCA is 162 mg once weekly, and the member must be at least 18 years of age. Reauthorization requires documentation of clinical response (improvement in signs and symptoms or inflammatory markers or imaging); initial and reauthorization approvals are for 12 months.

Definitions and Dosing

Tocilizumab SQ dosing for GCA

Recommended SQ dosing162 mg subcutaneously once every week

Concomitant therapyAdminister in combination with a tapering course of glucocorticoids

Dosing documentationPrescriber must provide dosing schedule and length of therapy on the authorization form

Verified GCA — diagnostic verification requirements

Verified diagnosis requirementGCA with large vessel arteritis must have been verified at some point by biopsy or vascular imaging (e.g., color Doppler ultrasound, MRI, PET-CT, or CT angiography)

Supporting documentationProvide biopsy report or imaging reports to support the verification

Verification accepted methodsBiopsy or imaging of the large vessels (CDUS, MRI, PET-CT, or CT angiography)

Initial Therapy

inv-13: Initial Therapy

Initial authorization requirements

Prescriber: Prescribed by or in consultation with a Neurologist, Ophthalmologist, or Rheumatologist

Prescriber signature required on form; incomplete forms may delay approval

Diagnosis verification: Giant Cell Arteritis with large vessel arteritis verified by biopsy or vascular imaging

Provide supporting biopsy or imaging reports; documentation required for each checked item

Age: Member is at least 18 years of age>=18 years

Corticosteroid trial: Member has tried one systemic corticosteroid

Trial must be documented in chart notes or claims

Dosing: 162 mg subcutaneous once weekly in combination with a tapering course of glucocorticoids

Provide dosing schedule and length of therapy on form

Requirement	Verification / Notes
Use of samples to initiate therapy
Previous therapies will be verified via pharmacy paid claims or submitted chart notes

OpenPayer

Prior authorization and step-edit criteria for subcutaneous tocilizumab (Actemra, Tyenne) — Giant Cell Arteritis

Coverage Criteria for SQ Tocilizumab (GCA)

Coding and Age Requirements

Provider Submission and Authorization Actions

Background

Definitions and Dosing

Initial Therapy

Continuation / Reauthorization

Step Therapy and Prior Treatment Verification

Site of Care and Dispensing