CurrentUCarePolicy Utilization Review Policy 133B

Inflammatory Conditions - Tocilizumab Intravenous Products Utilization Management Medical Policy

Prior authorization and utilization management policy for tocilizumab intravenous products (Actemra, Avtozma, Tofidence) for inflammatory and related indications across UCare plans (Medicare-specific lines noted). Defines preferred product step therapy, indication-specific authorization criteria, dosing limits, durations, supportive-evidence uses, and exclusions.

Policy Summary

PayerUCare

PolicyInflammatory Conditions - Tocilizumab Intravenous Products Utilization Management Medical Policy

Policy CodePolicy Utilization Review Policy 133B

Change TypePreferred biosimilar stepproduct additionsscope clarifications

Effective DateJan 1, 2020

Next Review Date

Key ActionSubmit prior authorization for tocilizumab intravenous and include chart notes documenting any step therapy exceptions; route oncology-related reviews to EviCore when applicable.

SourceLink

POLICY UPDATE CHANGES

Tyenne added as preferred biosimilar step effective 1/1/2025; preferred biosimilar step introduced.

Tofidence intravenous added to policy with same criteria as other products.

EviCore management noted for certain oncology/oncology-related reviews (e.g., CAR T-cell related CRS, Castleman disease, bispecific antibody CRS).

Policy statement updated to indicate acute treatment of COVID-19 in hospitalized patients is not addressed in this policy.

Wording changed from Actemra to tocilizumab throughout policy; policy renamed Inflammatory Conditions - Tocilizumab Intravenous Products.

Applies to patients new to therapy only; documented clinical need required for non-preferred product

Avtozma was added with same criteria as other tocilizumab IV products

Cytokine Release Syndrome associated with bispecific antibodies and Graft-Versus-Host Disease were added as conditions of approval

Giant Cell Arteritis corticosteroid requirement changed to 'tried or currently is taking' systemic corticosteroid unless contraindicated

Immunotherapy-related toxicities expanded from inflammatory arthritis to broader immunotherapy-related toxicities associated with checkpoint inhibitors; specialist list expanded and some prior therapy requirements removed

Removed requirement that a biosimilar prior use counts toward prior use for patients currently receiving tocilizumab

Updated step therapy criteria to require chart note documentation to support need for non-preferred product

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11+Indications addressed (FDA-approved and supportive evidence)

1Preferred biosimilar required for new starts

3Non-recommended conditions explicitly listed

2025-01-01Preferred biosimilar effective date

2024-04-24 to 2025-09-24Recent revision activity range

Coverage summary

Scope: This policy covers prior authorization and utilization management for intravenous tocilizumab products (Actemra, Avtozma, Tofidence) for multiple inflammatory and related indications across UCare plans, with a preferred biosimilar step (Tyenne) for new-to-therapy patients. Coverage is covered_with_criteria and aligns approvals with indication-specific criteria, dosing, and specialist involvement. Certain oncology and oncology-related reviews (indications noted with [EviCore]) are managed externally by EviCore. Effective date: 1/1/2020. Last review: 09/24/2025.

Compact policy facts

Policy numberUtilization Review Policy 133B

PayerUCare

Effective date2020-01-01

Last review2025-09-24

StatusCURRENT

Preferred biosimilar effective date2025-01-01 (Tyenne preferred for new-to-therapy patients)

Initial therapy criteria (by indication)

General Prior Authorization and Prescriber Requirement

General prior authorization and prescriber requirement.

All requests require prior authorization review.

Initial approval requires the drug to be prescribed by or in consultation with a physician who specializes in the condition being treated (e.g., rheumatologist, oncologist, hematologist, transplant specialist, or pediatric rheumatologist as appropriate).

Requests for doses outside the established dosing in this policy will be reviewed case-by-case by a clinician (Medical Director or Pharmacist).

Preferred product step therapy requirement applies: authorization for a non-preferred biologic (Actemra, Avtozma, Tofidence) will be granted only if any one of the following is met:

Continuation / established therapy criteria

Continuation / Currently Receiving criteria (selected indications)

Continuation (Currently Receiving) branches for covered indications. Approvals generally require establishment on therapy for specified minimum duration and evidence of objective or symptomatic improvement.

Continuation - Giant Cell Arteritis (Currently Receiving): Approve for 1 year if BOTH met: i) patient established on therapy ≥ 6 months; AND ii) patient meets at least ONE of: a) objective measure shows beneficial clinical response from baseline (e.g., CRP, ESR, resolution of fever, reduced corticosteroid dosage); OR b) improvement in at least one symptom (decreased headache, scalp, jaw pain; decreased fatigue; improved vision).

Continuation - pJIA (Currently Receiving): Approve for 1 year if BOTH met: i) patient established on therapy ≥ 6 months; AND ii) patient meets at least ONE of: a) objective measure shows beneficial clinical response from baseline (examples: MD global, PGA, PDA, JADAS, cJADAS, JSpADA, CRP, ESR, reduced corticosteroid dose); OR b) improvement in at least one symptom (improved motion, less joint pain/tenderness, decreased morning stiffness or fatigue, improved function/ADLs).

Continuation - Rheumatoid Arthritis (Currently Receiving):

Preferred biosimilar step therapy (new-to-therapy requirement)

Preferred Product Step Therapy Requirements

Authorization for a non-preferred biologic product or biosimilar will be granted if the patient meets ANY one of the following (A–E). Chart notes documenting the issue must be provided at the time of request:

ANY of the following

A. The patient is not considered a new start to the non-preferred product (new start is defined as no use of the requested product in the previous 365 days).
B. Allergic reaction to a specific inactive ingredient in all preferred biologic products or biosimilars.
C. Adverse reaction to a specific inactive ingredient in all preferred biologic products or biosimilars.
D. Therapeutic success while taking a non-preferred biologic product or biosimilar and therapeutic failure during an adequate trial of the preferred product (documented lack of efficacy, intolerance, or contraindication to the preferred product).

Provider actions, prior authorization & billing

Prior Authorization

Prior Authorization Required

Prior authorization is required for medical benefit coverage of tocilizumab intravenous products. Some oncology and oncology-related indications are managed by EviCore; prior authorization for those indications should be directed to EviCore. When requesting step therapy exceptions, submit chart notes documenting the clinical need at the time of the prior authorization request.

Documentation Required

Specialist Prescription/Consultation Requirement

Initial prescriptions must be written by or in consultation with a specialist appropriate to the treated condition. Accepted specialists include: rheumatologist; oncologist or hematologist; transplant physician (physician affiliated with a transplant center); gastroenterologist; hepatologist; and pulmonologist.

Rheumatologist
Oncologist or hematologist
Transplant physician (affiliated with transplant center)

Applicable products / codes

Products named in policymixedCovered

Actemra (tocilizumab intravenous infusion)	Actemra (tocilizumab intravenous infusion) - Genentech/Roche; listed FDA-approved product included in policy
Avtozma (tocilizumab-anoh intravenous infusion)	Avtozma (tocilizumab-anoh intravenous infusion) - Celltrion; biosimilar included in policy
Tofidence (tocilizumab-bavi intravenous infusion)	Tofidence (tocilizumab-bavi intravenous infusion) - Biogen; biosimilar included in policy
Tyenne	Tyenne; preferred biosimilar product (preferred product step therapy for patients new to therapy effective 2025-01-01)

Referenced products and examples (appendix)mixed

No codes listed

Billing: Specific HCPCS/J‑codes or NDCs for intravenous tocilizumab should be submitted on claims per usual billing practices. Prior authorization is required for medical benefit coverage and some oncology/oncology-related reviews are routed to EviCore for external prior authorization review.

Unproven / not recommended

Conditions Not Recommended for Approval

Coverage is not recommended in the following situations.

COVID-19: Coverage not recommended for COVID-19 outside the limited hospitalized adult indication; note policy does not address acute treatment of COVID-19 in hospitalized patients (that indication is separate and not targeted by this policy).
Concurrent biologic/targeted therapy: Concurrent use with another biologic or a targeted synthetic oral small molecule drug used for an inflammatory condition is not recommended (combination therapy generally not recommended).
Crohn's Disease: Coverage not recommended for Crohn's disease based on available pilot study evidence.

Clinical evidence & background

53-56%GiACTA: sustained remission at Week 52 with tocilizumab + prednisone taper vs 14-18% with prednisone-only

14-18%GiACTA: sustained remission at Week 52 with prednisone taper comparators

1Median IV tocilizumab doses in CAR T-cell CRS pivotal trial (range 1–4)

Background: Tocilizumab is an interleukin-6 (IL‑6) receptor inhibitor with multiple FDA‑approved inflammatory and related indications including rheumatoid arthritis, giant cell arteritis, polyarticular and systemic juvenile idiopathic arthritis, and cytokine release syndrome. This policy aligns approvals with indication‑specific criteria, dosing limits, and specialist prescriber or consultation requirements. Oncology and certain oncology-related indications noted with [EviCore] are managed externally by EviCore.

Definitions & dosing thresholds

Definitions and dosing thresholds

New start (definition)No use of the requested product in the previous 365 days.

Objective measures examplesSerum markers (CRP, ESR), standardized disease activity scores (CDAI, DAS28, JADAS, cJADAS, JSpADA), physician/patient global assessments, normalization of labs, resolution of fever, reduction in corticosteroid dose.

New to Therapy (definition)Patient not previously treated with the tocilizumab product class — triggers preferred biosimilar step (Tyenne) per UCare revision.

Weight-based dosing thresholdsDosing distinctions for <30 kg and ≥30 kg preserved across indications (examples: up to 12 mg/kg, 10 mg/kg, 8 mg/kg depending on indication).

Maximum per doseMaximum per dose specified as either 600 mg or 800 mg depending on indication and dosing regimen.

Dose interval minimums

Revision history

2025-01-01policy_change

Preferred biosimilar step introduced: Tyenne designated as the preferred biosimilar product for patients new to tocilizumab therapy; Tyenne must be used prior to Actemra and Tofidence for new starts unless clinical need documented.

2025-05-08policy_change

Step therapy documentation update: Step therapy criteria revised to require chart note documentation to support need for a non-preferred product (clinical need documented at time of request).

2024-06-06addition

Policy Summary

PayerUCare

PolicyInflammatory Conditions - Tocilizumab Intravenous Products Utilization Management Medical Policy

Policy CodePolicy Utilization Review Policy 133B

Change TypePreferred biosimilar stepproduct additionsscope clarifications

Effective DateJan 1, 2020

Next Review Date

Key ActionSubmit prior authorization for tocilizumab intravenous and include chart notes documenting any step therapy exceptions; route oncology-related reviews to EviCore when applicable.

SourceLink

On This Page

- The patient is not a new start to the requested non-preferred product (defined as prior use of the requested product within the previous 365 days).

- Documented allergy to a specific inactive ingredient in all preferred biologic products or biosimilars.

- Documented adverse reaction to a specific inactive ingredient in all preferred biologic products or biosimilars.

- Therapeutic success on the non-preferred biologic and therapeutic failure during an adequate trial of all preferred products (chart notes required).

- Clinical rationale why the preferred product is not appropriate for the patient (chart notes required).

Provider must submit supporting chart documentation for step therapy exceptions at time of request.

FDA-Approved Indications - Cytokine Release Syndrome (CAR T-cell therapy)

Criteria for cytokine release syndrome (CRS) associated with CAR T-cell therapy (initial therapy).

All of the following must be met for initial approval:

- Diagnosis of cytokine release syndrome associated with chimeric antigen receptor (CAR) T-cell therapy.

- Patient age ≥ 2 years.

- Severe or life-threatening CRS as assessed by treating team (per institutional grading system, e.g., ASTCT criteria).

- Drug intended for management of CRS in the setting of CAR T-cell therapy.

- Prescribed by or in consultation with the treating oncology team experienced in CAR T-cell therapy.

Dose and duration:

- Typical approval: single dose as clinically indicated; additional doses may be approved up to the dosing used in pivotal trials (median 1 dose; range 1–4 doses).

Operational note:

- Requests for prophylactic use with bispecific antibodies or other lymphocyte-engaging therapies (e.g., teclistamab, elranatamab, talquetamab) may be considered per NCCN guidance; specify if request is prophylactic and provide clinical rationale.

Giant Cell Arteritis

Giant cell arteritis (GCA) initial therapy criteria.

All of the following must be met for initial approval:

- Diagnosis of giant cell arteritis by a specialist (rheumatologist, neurologist, ophthalmologist, or vascular specialist) OR diagnosis supported by positive imaging consistent with GCA.

- Patient is adult (≥ 18 years).

- Prior or concurrent initiation of systemic corticosteroid therapy for GCA with documented response or use as bridge therapy (chart must show corticosteroid use and dose).

- Prescribed by or in consultation with a specialist experienced in management of GCA.

Dose thresholds and approval duration:

- Dosing consistent with product labeling for GCA (e.g., tocilizumab subcutaneous or IV regimens per approved labeling).

Operational note:

- Prior corticosteroid requirement: because pivotal trials included patients treated with corticosteroids during screening and taper, documentation of corticosteroid initiation or intent to use corticosteroids as part of the treatment plan is required for initial approvals.

- For continuation therapy, patient must demonstrate clinical benefit (reduced relapse or steroid-sparing) and ongoing specialist follow-up.

Polyarticular Juvenile Idiopathic Arthritis (pJIA)

Polyarticular juvenile idiopathic arthritis (pJIA) initial therapy criteria.

All of the following must be met for initial approval in patients with pJIA:

- Diagnosis of active polyarticular juvenile idiopathic arthritis.

- Patient age ≥ 2 years.

- Prescribed by or in consultation with a pediatric rheumatologist.

- One of the following prior therapy requirements must be met:

- Prior trial and inadequate response or intolerance to a conventional synthetic DMARD (e.g., methotrexate) unless biologic is being used as initial therapy in special circumstances per ACR guidance; OR

- Clinical rationale for earlier use of biologic (e.g., severe disease, joint-threatening disease such as TMJ involvement) documented in chart.

Dose thresholds:

- Dosing must be consistent with product labeling for weight- and age-based dosing for pJIA.

Operational note:

- For patients currently receiving tocilizumab prior to authorization request, documentation of prior response and ongoing specialist follow-up is required.

Rheumatoid Arthritis

Rheumatoid arthritis initial therapy criteria.

All of the following must be met for initial approval:

- Diagnosis of moderate to severe active rheumatoid arthritis.

- Age ≥ 18 years.

- Inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, unless contraindicated or not tolerated (document rationale).

- Prescribed by or in consultation with a rheumatologist.

Dose thresholds:

- Dosing consistent with the approved rheumatoid arthritis dosing regimens and monitoring recommendations.

Operational note:

- Dosing modifications for laboratory abnormalities (e.g., elevated liver enzymes, neutropenia, thrombocytopenia) follow labeling; documentation of monitoring plan is required.

Systemic Juvenile Idiopathic Arthritis (SJIA) / Still's Disease / AOSD

Systemic juvenile idiopathic arthritis (sJIA) / Still's disease initial therapy criteria.

All of the following must be met for initial approval for sJIA (including SJIA and adult-onset Still's disease considerations):

- Diagnosis of systemic juvenile idiopathic arthritis (sJIA) or adult-onset Still's disease (AOSD) as documented by a rheumatologist.

- Patient age ≥ 2 years for sJIA; for AOSD, adult age as appropriate.

- Prior therapy requirements:

- For AOSD (adult-onset Still's disease), documentation of prior trial and inadequate response to at least one conventional therapy and prior biologic requirements per policy note where applicable; OR

- If guideline-supported early biologic initiation is chosen, documentation of rationale per EULAR/PReS recommendations is required.

- Prescribed by or in consultation with a rheumatologist.

Dose thresholds:

- Dosing consistent with product labeling for sJIA/AOSD and weight/age-based adjustments.

Operational notes and revisions:

- Removal of prior requirements: certain previous requirements related to Still's disease/SJIA have been revised — ensure current chart documentation reflects updated criteria and any prior biologic history if relevant.

- For patients currently receiving tocilizumab, document clinical benefit and ongoing specialist management.

Other Uses with Supportive Evidence (initial criteria)

Other uses with supportive evidence (initial therapy) — split by indication.

Castleman Disease (multicentric or selected unicentric cases):

All of the following must be met for initial approval:

- Diagnosis of Castleman disease (multicentric or relapsed/refractory unicentric) documented by treating specialist.

- Patient is HIV-negative and HHV-8 status documented when relevant (per guideline recommendations).

- Prescribed by or in consultation with a hematologist/oncologist.

- Dosing consistent with guideline or labeling for Castleman disease.

Bispecific-antibody associated CRS (prophylactic/short approval):

All of the following must be met for initial short-course approval:

- Use intended to prevent or treat CRS in the setting of bispecific antibody therapy (e.g., teclistamab, elranatamab, talquetamab) per NCCN guidance.

- Prescribed by treating oncology team.

- Short initial approval allowed (specify prophylactic intent) — duration limited and requires documentation of administration plan; additional doses require clinical justification.

Graft-versus-Host Disease (GVHD):

All of the following must be met for initial approval for acute steroid-refractory GVHD:

- Diagnosis of acute GVHD with steroid-refractory disease.

- Prescribed by or in consultation with a transplant specialist or hematologist.

- Dosing consistent with institutional protocols and NCCN guidance.

Immunotherapy-related toxicities associated with checkpoint inhibitor therapy:

All of the following must be met for initial approval:

- Immune checkpoint inhibitor-related severe toxicity (examples: HLH-like syndrome, severe inflammatory arthritis, severe pneumonitis, hepatobiliary immune-related adverse events) not responsive to corticosteroids.

- Prescribed by or in consultation with the treating oncology team.

- Documentation of prior steroid therapy and lack of adequate response, unless contraindicated.

Polymyalgia Rheumatica (PMR):

All of the following must be met for initial approval:

- Diagnosis of polymyalgia rheumatica by a specialist.

- Prior adequate trial of glucocorticoids with documented response or intolerance to glucocorticoids and rationale for IL-6 inhibitor use.

Adult-onset Still's Disease (AOSD):

All of the following must be met for initial approval:

- Diagnosis by a rheumatologist.

- Documentation of prior conventional therapy trial and inadequate response OR documentation supporting early biologic initiation per guidelines.

- Prescribed by or in consultation with a rheumatologist.

COVID-19 statement:

- The acute treatment of COVID-19 in hospitalized patients is not the focus of this policy; however, tocilizumab has guideline-supported use for hospitalized patients with progressive severe or critical COVID-19 with elevated inflammatory markers — such requests should be adjudicated according to the payer's COVID-19 treatment benefit and any separate COVID-19-specific guidance.

Operational notes for this group:

- For each indication above, requests must include specialist documentation, indication-specific supportive data, and dosing consistent with labeling or guideline-supported regimens.

- Bispecific-antibody CRS prophylactic uses are time-limited initial approvals; ongoing dosing beyond initial short-course requires justification and documentation of the treatment plan.

Approve for 1 year if BOTH met: i) patient established on therapy ≥ 6 months; AND ii) patient experienced beneficial clinical response by at least one objective measure (examples: CDAI, DAS28-ESR or CRP, PAS-II, RAPID-3, SDAI) OR improvement in at least one symptom (decreased joint pain, morning stiffness, fatigue; improved function/ADLs).

Continuation - SJIA (Currently Receiving): Approve for 1 year if BOTH met: i) patient established on therapy ≥ 6 months; AND ii) patient meets at least ONE of: a) objective measure improvement (e.g., resolution of fever, improvement in rash, normalization of CRP/ESR, reduced corticosteroid dose); OR b) improvement in at least one symptom (less joint pain/tenderness, decreased fatigue, improved function/ADLs).

Continuation - Supportive Indications (Currently Receiving): For Castleman Disease, GVHD, Immunotherapy-related toxicities, Polymyalgia Rheumatica, AOSD and other supportive indications: Approve for indication-specific durations (e.g., Castleman 1 year, GVHD 3 months, Immunotherapy-related toxicities 1 year, Polymyalgia Rheumatica 1 year, AOSD 1 year) if patient has been established on therapy for the specified minimum duration (commonly ≥1–6 months as indicated) AND demonstrates objective or symptomatic improvement from baseline per the indication's criteria.

Approval durations vary by indication: initial approvals are commonly 6 months for many indications with established criteria, continuation (patients currently receiving therapy) approvals are commonly 1 year, and cytokine release syndrome (CAR T-cell or bispecific antibody–associated CRS) approvals are 1 week (adequate for up to four doses). Other indications have specific durations (e.g., GVHD initial approval 1 month with shorter established-therapy durations).

E. Other clinically appropriate reason documented in chart notes that justifies use of the non-preferred product instead of the preferred product (e.g., documented medical necessity, clinician judgment, or specific patient circumstances).

Step Therapy

Preferred biosimilar step therapy (new-to-therapy requirement)

Preferred biosimilar step therapy and documentation requirements for providers.

Preferred product: Tyenne (effective 2025-01-01)
Preferred biosimilar required for new-to-therapy patients: new-to-therapy patients must be started on the preferred product Tyenne; exceptions listed in the Preferred Product Step Therapy Requirements (A–E) allow approval of a non-preferred product.
Chart documentation for non-preferred product: chart-note documentation supporting the exception must be provided at the time of request (requirement updated 2025-05-08). Examples of acceptable documentation include prior treatment history, dates of prior product use, description of allergic/adverse reactions, clinical rationale for continued use, and relevant lab or clinical findings.

Billing Rule

Approval Durations and Units

Approvals are granted for indication-specific durations (examples): initial approvals commonly 6 months for many indications, 1 year for patients currently receiving therapy, 1 week for cytokine release syndrome (adequate to receive up to four doses), and 1 month for certain GVHD initial approvals. Note: when approvals are given in months, 1 month = 30 days.

Common durations: 6 months (many initial therapies); 1 year (established on therapy)
CRS/bispecific antibody CRS: 1 week (up to four doses)
GVHD initial: 1 month
Conversion: 1 month = 30 days

Denial Risk

Not Recommended Situations

Coverage is not recommended and may be denied for listed exclusions: COVID-19 outside the policy scope (acute hospitalized COVID-19 not addressed here and intravenous tocilizumab for COVID-19 is limited to specific hospitalized scenarios), concurrent use with another biologic or targeted synthetic oral small molecule for inflammatory conditions (combination therapy not recommended), Crohn's disease (evidence insufficient), and other circumstances not listed in the Recommended Authorization Criteria.

COVID-19 outside the policy scope (policy does not address acute hospitalized COVID-19)
Concurrent use with another biologic or targeted synthetic oral small molecule (combination therapy not recommended)
Crohn's disease (coverage not recommended)
Circumstances not listed in the Recommended Authorization Criteria

Documentation Required

HIV and HHV-8 testing for Castleman disease initial therapy

For initial approval of Castleman disease, the provider must document that the patient is negative for HIV and negative for HHV-8; these test results must be included in the medical record and provided with the request.

Documented negative HIV result required for Castleman disease initial therapy
Documented negative HHV-8 result required for Castleman disease initial therapy

Documentation Required

Specialist attestation for immunotherapy-related toxicities

When prescribing for immunotherapy-related toxicities associated with checkpoint inhibitors, the prescriber must attest that the toxicity developed while the patient was receiving a checkpoint inhibitor and provide treatment details. Accepted specialists for initial prescribing or consultation include rheumatologists, gastroenterologists, hepatologists, pulmonologists, and oncologists.

Prescriber attestation that toxicity developed while on a checkpoint inhibitor
Accepted specialists: rheumatologist, gastroenterologist, hepatologist, pulmonologist, oncologist
Provide treatment details and supporting documentation with the request

Other: Coverage not recommended for circumstances not listed in the Recommended Authorization Criteria.

Clarification: Acute treatment of COVID-19 in hospitalized patients is not addressed by this policy; although intravenous tocilizumab has a labeled hospitalized-COVID indication under specific circumstances, that acute hospitalized COVID-19 use is outside the scope targeted by this policy.

Interval minimums vary by indication (examples: ≥8 hours between CRS doses; ≥1 week for SJIA/Castleman; ≥2 weeks; ≥4 weeks for RA/GCA/pJIA/immunotherapy-related toxicities).

Age cross-reference: For Still's disease/SJIA guidance the policy uses age-based references — patients <18 years are directed to the SJIA criteria, while patients ≥18 years are directed to the adult-onset Still's disease (AOSD) criteria.

Tofidence (tocilizumab-bavi) intravenous added to the policy with the same criteria as other tocilizumab IV products.

2025-09-24additionLatest

Avtozma (tocilizumab-anoh) added to the policy with the same criteria as other tocilizumab IV products.

2025-08-13addition

New indications added: Cytokine Release Syndrome associated with bispecific antibodies and Graft-Versus-Host Disease were added as conditions of approval (criteria and dosing mirrored CAR T-cell CRS/other indication formats).

2025-06-11policy_change

Giant Cell Arteritis corticosteroid requirement revised to specify the patient has 'tried or currently is taking' a systemic corticosteroid, unless systemic corticosteroids are contraindicated.

2025-06-11policy_change

Immunotherapy-related toxicities expansion and specialist update: Condition expanded from inflammatory arthritis to broader immunotherapy-related toxicities associated with checkpoint inhibitors; specialist list expanded to include gastroenterologist, hepatologist, and pulmonologist; some prior therapy requirements removed.

2024-04-24terminology_update

Terminology and policy name updated to encompass multiple tocilizumab products: wording changed from Actemra to tocilizumab throughout and policy renamed 'Inflammatory Conditions - Tocilizumab Intravenous Products.'

2024-04-23clarification

COVID-19 scope clarified: Policy statement updated to indicate acute treatment of COVID-19 in hospitalized patients is not addressed in this policy; COVID-19 language for non-hospitalized treatment was generalized.