CurrentMass General Brigham Health PlanPolicy N/A

Tofidence (tocilizumab-bavi) Effective 01/06/2025

Policy Summary

PayerMass General Brigham Health Plan

PolicyTofidence (tocilizumab-bavi) Effective 01/06/2025

Policy CodePolicy N/A

Change TypeClarified (created for P&Tadopted MassHealth criteria)

Effective DateJan 6, 2025

Next Review Date

Key ActionTofidence is managed with prior authorization via the pharmacy benefit (medical benefit noted); authorizations reviewed case-by-case for members new to plan or when all indication-specific criteria are met. Requests for cytokine release syndrome must include anticipated CAR T-cell administration date.

SourceLink

POLICY UPDATE CHANGES

Created for P&T. Adopted MassHealth criteria: Tofidence will be managed with PA via MB only.

6Indications listed in overview

6 monthsInitial approval duration

1 yearReauthorization duration

Coverage Summary

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Pharmacy benefit prior authorization policy for Tofidence (tocilizumab-bavi) governing authorization criteria, quantity/step therapy/limits, dosing conformity to FDA labeling, initial and reauthorization durations, and requests for higher or more frequent dosing. Tofidence is covered with prior authorization under the pharmacy benefit and applies to commercial/exchange and MassHealth plans. Management and review follow MassHealth-adopted criteria: authorizations are reviewed case-by-case for members new to the plan and initial approvals are granted for 6 months with reauthorizations for 1 year. Per the review history, Tofidence will be managed with prior authorization via the medical benefit noted; contact information for pharmacy and medical prior authorization is provided in plan materials.

General Authorization Conditions

Authorization may be granted when ALL of the following are met:

Member new to plan

Authorization may be reviewed on a case by case basis for members who are new to the plan currently receiving treatment with requested medication (excluding when the product is obtained as samples or via manufacturer's patient assistance programs)

ALL of the following

Requested authorization meets one of the indication-specific criteria below

Cytokine release syndrome