Actemra (tocilizumab), Tofidence, Tyenne prior authorization
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Prior authorization form and clinical criteria used by CVS Caremark on behalf of HMSA Medicare Advantage to determine coverage for Actemra, Tofidence, and Tyenne for specified indications. Applies to prescribers requesting coverage for these medications under the patient's prescription/specialty benefit.
No material clinical or coverage changes in this revision.
Coverage Criteria and Decision Logic
Form-driven clinical criteria
Coverage determination follows condition-specific branching questions; approval depends on the selected diagnosis, current treatment status, and documentation of prior response or progression as specified below.
See continuation question flow (Q3 and Q4).
See Q7.
See Q8–Q13.
See Q14–Q19.
The prior authorization form uses branching logic that directs the reviewer through condition-specific pathways. Several diagnosis options end with an "Other, No Further Questions" branch; when that branch is selected the form does not continue through the detailed indication-specific questions. In practice, selecting Other, No Further Questions means the requester will not proceed through the form’s subsequent diagnostic or treatment-history gates on this form and coverage determination will rely on the information provided for that alternative diagnosis or on separate review processes.
When a listed diagnosis follows an Other selection (for example when the form offers the explicit option Other; No Further Questions at initial diagnosis prompts), the form’s detailed criteria for labeled indications (e.g., RA, JIA, GCA, SSc-ILD, Castleman disease, CRS) are not applied automatically; reviewers should recognize that those cases require either supplemental documentation or adjudication outside the form’s standard branching flow.
The form does not include explicit wording that any listed use is "not medically necessary." Instead, denials are driven by the branching criteria themselves: if a patient fails to meet required branch conditions (for example failing to meet an indication-specific question or required response to prior therapy), the form yields "No Further Questions" outcomes that effectively terminate approval for that pathway. Reviewers should therefore base denial rationale on unmet branching criteria or missing required documentation rather than on a standalone "not medically necessary" statement.
Coding and Patient Measurements
| Field on form: 'What is the ICD-10 code?' (no specific codes provided) |
Provider Actions and Documentation Requirements
Prior Authorization Required
Prior authorization is required for coverage of the prescribed medication under the member's prescription/specialty benefit and is administered by CVS Caremark. Providers must submit prior authorization requests to CVS Caremark (toll-free 1-866-237-5512). Failure to obtain the required authorization prior to dispensing may result in claim denial or non-coverage.
- Contact CVS Caremark for PA: 1-866-237-5512
- Specialty Customer Care / benefit questions: CaremarkConnect@ / 1-800-237-2767
Accurate Diagnosis and Supporting Documentation
Prescribers must attest that the diagnosis submitted on the prior authorization form is accurate and provide supporting clinical documentation. This includes the indication for use, relevant clinical findings, and any progress notes that substantiate the need for the requested drug.
- Provide accurate primary diagnosis on the PA form
- Attach relevant progress notes and clinical documentation
High-Resolution CT (HRCT) Results Required for SSc-ILD
For evaluations of systemic sclerosis–associated interstitial lung disease (SSc-ILD), a high-resolution computed tomography (HRCT) of the chest must be obtained and the results made available. HRCT results should be submitted upon request to support the diagnosis and treatment decision.
- If diagnosis = SSc-ILD, submit HRCT chest results upon request
Prior Treatment and Response Documentation
Documentation of prior treatments and the clinical response is required to demonstrate medical necessity. Include prior and concurrent therapies (for example systemic corticosteroids, disease-modifying antirheumatic drugs, prior biologic agents), dates of therapy, reasons for discontinuation (e.g., lack of efficacy or unacceptable toxicity), and evidence of benefit or progression as applicable.
- List prior/concurrent therapies with dates (e.g., corticosteroids, DMARDs, prior biologics)
- Document response: clinical benefit, lack of efficacy, or unacceptable toxicity
- If applicable, document disease progression while on prior regimens
Failure to Obtain Prior Authorization May Result in Non-Coverage
Failure to obtain required prior authorization from CVS Caremark may result in denial of coverage for the medication. Ensure all requested documentation is submitted with the PA to avoid claim delay or denial.
- Non-coverage risk if PA not received from CVS Caremark
- Submit complete PA and supporting documents to avoid denial
Background and Scope
This prior authorization form covers multiple labeled indications for tocilizumab (Actemra) and related products, including: rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), giant cell arteritis (GCA), systemic sclerosis‑associated interstitial lung disease (SSc‑ILD), unicentric and multicentric Castleman disease, immunotherapy‑related inflammatory arthritis, chimeric antigen receptor (CAR) T cell‑induced cytokine release syndrome (CRS), graft‑versus‑host disease, and thyroid eye disease. The form collects diagnosis selection, current treatment status, prior treatment history and response, and certain disease‑specific confirmations (for example, an HRCT of the chest may be required and must be submitted upon request for SSc‑ILD).
Definitions and Operational Terms
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