Actemra (tocilizumab)
Billing
Code: J3262
Description: Tocilizumab injection
Unit: 1 mg
Payment: $5.989
Pay quarter: Q1 2023
Dosage and Frequency
Rheumatoid Arthritis (RA)
Induction:
• 4mg/kg IV every 4 weeks
Maintenance:
• 4mg/kg or 8mg/kg IV every 4 weeks
OR
Induction:
• 162mg SQ every 2 weeks if patient weighs less than 100kg
• 162mg SQ every 1 week if patient weighs greater than or equal to 100kg
Maintenance:
• 162mg SQ every 2 weeks or every 1 week
Induction:
• 4mg/kg IV every 4 weeks
Maintenance:
• 4mg/kg or 8mg/kg IV every 4 weeks
OR
Induction:
• 162mg SQ every 2 weeks if patient weighs less than 100kg
• 162mg SQ every 1 week if patient weighs greater than or equal to 100kg
Maintenance:
• 162mg SQ every 2 weeks or every 1 week
Giant Cell Arteritis (GCA)
• 6mg/kg IV every 4 weeks
OR
• 162mg SQ every 1 week
• 6mg/kg IV every 4 weeks
OR
• 162mg SQ every 1 week
Systemic Sclerosis-Associated Interstitial Lung Disease (SSc-ILD)
• 162mg SQ every 1 week
• 162mg SQ every 1 week
Polyarticular Juvenile Idiopathic Arthritis (PJIA)
• 10mg/kg IV every 4 weeks if patient weighs less than 30kg
• 8mg/kg IV every 4 weeks if patient weighs greater than or equal to 30kg
OR
• 162mg SQ every 3 weeks if patient weighs less than 30kg
• 162mg SQ every 2 weeks if patient weighs greater than or equal to 30kg
• 10mg/kg IV every 4 weeks if patient weighs less than 30kg
• 8mg/kg IV every 4 weeks if patient weighs greater than or equal to 30kg
OR
• 162mg SQ every 3 weeks if patient weighs less than 30kg
• 162mg SQ every 2 weeks if patient weighs greater than or equal to 30kg
Systemic Juvenile Idiopathic Arthritis (SJIA)
• 12mg/kg IV every 2 weeks if patient weighs less than 30kg
• 8mg/kg IV every 2 weeks if patient weighs greater than or equal to 30kg
OR
• 162mg SQ every 2 weeks if patient weighs less than 30kg
• 162mg SQ every 1 week if patient weighs greater than or equal to 30kg
• 12mg/kg IV every 2 weeks if patient weighs less than 30kg
• 8mg/kg IV every 2 weeks if patient weighs greater than or equal to 30kg
OR
• 162mg SQ every 2 weeks if patient weighs less than 30kg
• 162mg SQ every 1 week if patient weighs greater than or equal to 30kg
Cytokine Release Syndrome (CRS)
• 12mg/kg IV if patient weighs less than 30kg
• 8mg/kg IV if patient weighs greater than or equal to 30kg
Up to 3 additional dosages may be administered depending on clinical response, with at least 8 hours in between each consecutive dose.
• 12mg/kg IV if patient weighs less than 30kg
• 8mg/kg IV if patient weighs greater than or equal to 30kg
Up to 3 additional dosages may be administered depending on clinical response, with at least 8 hours in between each consecutive dose.
Calculate drug reimbursement
Total Reimbursement:
$3,555.07(ASP: $3,353.84, Margin: $201.23)
Code:
J3262# Units to bill:
560Prior Authorization
Prior auth criteria for Actemra may include but is not limited to:
• Diagnosis of Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, Giant Cell Arteritis, or Systemic Lupus Erythematosus
• Failed response to at least one DMARD or biologic
• Documented evidence of active disease
• Body Weight of at least 40 kg
• Patient is not pregnant or lactating
• Patient is 18 years of age or older
• Patient is not on chronic dialysis
• Patient does not have active hepatitis B or C
• Patient does not have a history of interstitial lung disease
• Patient does not have any active malignancy
• Patient does not have a history of active tuberculosis
• Patient does not have a hemoglobin level below 8.0 g/dl
• Patient does not have a platelet count below 150,000/mm3
• Patient does not have a neutrophil count below 500/mm3
• Patient does not have an absolute lymphocyte count below 500/mm3
• Patient does not have an elevated liver enzyme test result
Insurance prior auth guidelines:
Billable NDCs
50242-0135-01
Actemra (GENENTECH, INC.)
80 MG
50242-0136-01
Actemra (GENENTECH, INC.)
200 MG
50242-0137-01
Actemra (GENENTECH, INC.)
400 MG
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