CurrentHawaii Medical Service Association (HMSA)Policy N/A

Actemra, Avtozma, Tofidence, and Tyenne (tocilizumab) Coverage Criteria

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Outpatient coverage and precertification for four tocilizumab products in Medicare Advantage members for specified FDA-approved and compendial indications when applicable criteria are met; hospitalized COVID-19 treatment is managed under the inpatient benefit.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyActemra, Avtozma, Tofidence, and Tyenne (tocilizumab) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Last ReviewMay 1, 2025

Next Review DateN/A

Key ActionPrecertification is required for covered tocilizumab products; use the applicable fax form from the HMSA medical specialty drug policy website.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Tocilizumab products covered

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CurrentHawaii Medical Service Association (HMSA)Policy N/A

Actemra, Avtozma, Tofidence, and Tyenne (tocilizumab) Coverage Criteria

Customize your policy alerts

Sign up for all Hawaii Medical Service Association (HMSA) policy alerts

Know when Hawaii Medical Service Association (HMSA) releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyActemra, Avtozma, Tofidence, and Tyenne (tocilizumab) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Last ReviewMay 1, 2025

Next Review DateN/A

Key ActionPrecertification is required for covered tocilizumab products; use the applicable fax form from the HMSA medical specialty drug policy website.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Tocilizumab products covered

6FDA-approved indications

12 monthsStandard authorization period

1 monthCRS authorization period

Covered Indications and Authorization Rules

Initial Covered Indications

Coverage may be granted when all applicable approval criteria are met and the member has no exclusion to the prescribed therapy. The requested agent must be used for one of the FDA-approved or compendial indications listed below.

ALL of the following

The member has no exclusion to the prescribed therapy.
ONE of the following covered indications
- Moderately to severely active rheumatoid arthritis in an adult who has had an inadequate response to one or more disease-modifying anti-rheumatic drugs.
- Rheumatoid arthritis with no previous treatment failure; authorization may be granted for 12 months.
- Giant cell arteritis; authorization may be granted for 12 months.
- Polyarticular or systemic juvenile idiopathic arthritis in a patient 2 years of age or older; authorization may be granted for 12 months.
- Chimeric antigen receptor (CAR) T cell-induced severe or life-threatening cytokine release syndrome (CRS) in an adult or pediatric patient 2 years of age or older; authorization may be granted for 1 month.
- Cytokine release syndrome in a member with refractory CRS related to blinatumomab therapy; authorization may be granted for 1 month.
- Unicentric Castleman disease; authorization may be granted for 12 months.
- Multicentric Castleman disease; authorization may be granted for 12 months.
- Immunotherapy-related inflammatory arthritis; authorization may be granted for 12 months.
- Acute graft versus host disease; authorization may be granted for 12 months.
- Thyroid eye disease, including active Graves' orbitopathy; authorization may be granted for 12 months.
- Polymyalgia rheumatica (PMR); authorization may be granted for 12 months.
- Another indication supported by evidence from a Medicare-approved compendium; all indications other than those listed in this policy are assessed on an individual basis.

Initial Authorization When No Prior Approval Exists

All members, including new members and members currently receiving treatment without prior authorization, must meet the initial authorization criteria.

{"text":"No previous authorization or precertification exists for the requested therapy."},{"text":"The member meets the applicable initial covered-indication criteria in this policy."}

Continuation: Cytokine Release Syndrome or Acute Graft Versus Host Disease

All members, including new members, requesting continuation of therapy for cytokine release syndrome or acute graft versus host disease must meet the applicable initial authorization criteria.

ALL of the following

ONE of the following diagnoses
- Cytokine release syndrome.
- Acute graft versus host disease.
All applicable initial authorization criteria are met.

Continuation: All Other Diagnoses

Authorization for continuation of therapy may be granted for 12 months when all of the following criteria are met.

ALL of the following

The member is currently receiving therapy with the requested medication.
The requested medication is being used to treat an indication listed in the coverage criteria section.
The member is receiving benefit from therapy.

Adult patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD) are not covered under this policy because the drug approved for this indication is usually self-administered. The indication is for slowing the rate of decline in pulmonary function.

These criteria apply only to coverage in the outpatient setting. Hospitalized members receiving treatment for COVID-19 are managed according to the member's inpatient benefit.

Initial Therapy

Initial authorization may be granted when the member has a covered indication and meets all applicable approval criteria.

Covered indication

Rheumatologic indications: Rheumatoid arthritis, giant cell arteritis, polyarticular or systemic juvenile idiopathic arthritis, or polymyalgia rheumatica.Authorization: 12 months
Cytokine-mediated indications: CAR T cell-induced cytokine release syndrome or refractory cytokine release syndrome related to blinatumomab therapy.Authorization: 1 month
Other covered indications: Unicentric or multicentric Castleman disease, immunotherapy-related inflammatory arthritis, acute graft versus host disease, or active Graves' orbitopathy or thyroid eye disease.

Continuation Therapy

Continuation for Cytokine Release Syndrome and Acute Graft Versus Host Disease

For cytokine release syndrome and acute graft versus host disease, continuation requests must meet all initial authorization criteria.

Initial criteria for continuation: All initial authorization criteria must be met.

Applies to continuation of therapy for cytokine release syndrome and acute graft versus host disease.

Continuation for Other Diagnoses

For all other diagnoses, authorization for 12 months may be granted when all criteria are met.

Other-diagnosis reauthorization

Current medication: The member is currently receiving therapy with the requested medication.

Submission, Documentation, and Denial Risks

Prior Authorization

Precertification Required

Precertification is required for tocilizumab products. Refer to the HMSA medical specialty drug policy website for the applicable fax form and submission instructions.

Documentation Required

Thyroid Eye Disease: Document First-Line Treatment Failure

For thyroid eye disease, document that the member has moderate to severe, active disease that was unresponsive to first-line therapy before requesting second-line tocilizumab.

Document prior treatment with IV methylprednisolone in combination with oral mycophenolate sodium or mofetil, when applicable.
Document glucocorticoid-resistant or otherwise unresponsive disease.

Documentation Required

Prerequisite and Sequencing Requirements

Step	Condition	Requirement
1	Moderate or severe immunotherapy-related inflammatory arthritis	Consider tocilizumab as additional disease-modifying antirheumatic therapy after holding immunotherapy and treating with oral corticosteroids, when there is no improvement or corticosteroids cannot be tapered.

Step	Condition	Requirement
1	Acute graft versus host disease	Use tocilizumab as additional therapy in conjunction with systemic corticosteroids after no response to first-line therapy options, including steroid-refractory disease.

Step	Condition	Requirement
2	Active moderate-to-severe Graves' orbitopathy	Use tocilizumab as second-line treatment after failure or lack of response to first-line therapy. Intravenous methylprednisolone with oral mycophenolate is identified as first-line therapy.

Step	Condition	Requirement
1	Polymyalgia rheumatica	Consider tocilizumab as additional disease-modifying antirheumatic therapy when prednisone cannot be tapered or symptoms do not improve.

Outpatient Coverage Scope

Note

Apply the policy to outpatient treatment only

The criteria in this policy apply only to outpatient coverage. Hospitalized members receiving treatment for COVID-19 are managed according to the member’s inpatient benefit rather than these outpatient criteria.

Key Clinical Terms

CAR T cell-induced cytokine release syndrome

DefinitionA severe or life-threatening inflammatory response associated with chimeric antigen receptor (CAR) T-cell therapy.

Hospitalized COVID-19

DefinitionCoronavirus disease 2019 (COVID-19) requiring hospitalization in an adult patient receiving systemic corticosteroids and requiring supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).

Policy Context

Tocilizumab products are covered for selected inflammatory and rheumatologic conditions, including rheumatoid arthritis, giant cell arteritis, juvenile idiopathic arthritis, thyroid eye disease, and polymyalgia rheumatica. The policy also addresses oncologic-supportive and cytokine-mediated uses, including cytokine release syndrome and immunotherapy-related inflammatory arthritis, as well as transplant-related treatment for acute graft versus host disease. Coverage includes specified FDA-approved and compendial indications; authorization is generally for 12 months, with 1 month specified for cytokine release syndrome.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyActemra, Avtozma, Tofidence, and Tyenne (tocilizumab) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Last ReviewMay 1, 2025

Next Review DateN/A

Key ActionPrecertification is required for covered tocilizumab products; use the applicable fax form from the HMSA medical specialty drug policy website.

SourceLink

On This Page

Authorization: 12 months

COVID-19: Hospitalized adult COVID-19 meeting the specified systemic corticosteroid and respiratory-support criteria.

Hospitalized COVID-19 treatment is managed under the member's inpatient benefit.

Covered indication: The requested medication is being used to treat an indication listed in the coverage criteria section.

Benefit from therapy: The member is receiving benefit from therapy.

Inflammatory Arthritis: Document Prior Management

For immunotherapy-related inflammatory arthritis, document that immunotherapy was held and oral corticosteroids were tried without improvement, or that the provider was unable to taper corticosteroids, before requesting tocilizumab.

Documentation Required

Acute Graft-versus-Host Disease: Document Steroid-Refractory Disease

For acute graft-versus-host disease, document that tocilizumab will be used with systemic corticosteroids after inadequate response to first-line treatment options.

Document steroid-refractory disease or no response to first-line therapy.

Documentation Required

Polymyalgia Rheumatica: Document Prednisone Response

For polymyalgia rheumatica, document that the member is unable to taper prednisone or has not had adequate improvement in symptoms before requesting tocilizumab.

Document the prednisone treatment course and inability to taper, when applicable.
Document persistent symptoms or inadequate symptom improvement, when applicable.

Unsupported block type: documentation

Prior Authorization

Submit the Precertification Fax Form

Obtain and use the applicable precertification fax form from the HMSA medical specialty drug policy website when submitting a request.

Note

Reconsideration Requires Supporting Documentation

If the physician disagrees with an HMSA or HMSA Pharmacy Benefit Manager medical necessity determination, the physician may request reconsideration of the case with supporting documentation.

Include documentation supporting why the medical necessity criteria should be reconsidered.

Denial Risk

Unlisted Indication or Exclusion

A request is at risk of denial when the indication is not FDA-approved or listed in the coverage criteria and the submission does not include supporting evidence from Medicare-approved compendia.

Unlisted indications are assessed individually.
Submit applicable compendial evidence to support the requested use.

Denial Risk

Self-Administered SSc-ILD Is Generally Excluded

The FDA-approved SSc-ILD indication is generally excluded from this policy because the drug approved for that indication is usually self-administered.

Adult systemic sclerosis-associated interstitial lung disease (SSc-ILD) for slowing the rate of decline in pulmonary function.

Denial Risk

Continuation Criteria Must Be Met

Continuation authorization for diagnoses other than cytokine release syndrome or acute graft-versus-host disease may be granted for 12 months only when all continuation criteria are met. Requests may be denied if the member is not currently receiving the requested agent, the indication is not listed in the coverage criteria, or the member is not benefiting from therapy.

The member must be currently receiving the requested medication.
The medication must be used for an indication listed in the coverage criteria.
The member must be receiving benefit from therapy.