Medicare AdvantagePrior AuthHigh impact
Intravenous tocilizumab products (Revised)
Humana·Rheumatology, Oncology, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2019
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its prior authorization policy for intravenous tocilizumab products (Actemra, Tyenne, Tofidence, Avtozma) effective January 1, 2019, with the most recent revision dated October 22, 2025. The policy establishes specific clinical criteria and exclusions for coverage across five indications: rheumatoid arthritis, systemic juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, cytokine release syndrome, and giant cell arteritis. Billing teams must implement prior authorization requirements and enforce step therapy protocols requiring documented prior therapy or contraindications with specific biologics before tocilizumab approval.
Action Required
Immediately: Billing and clinical teams must implement prior authorization procedures for all intravenous tocilizumab products (Actemra, Tyenne, Tofidence, Avtozma) under this Humana Medicare Advantage policy. Update billing system to require prior auth for HCPCS codes J9310, J9311, and J9312. For rheumatoid arthritis and cytokine release syndrome cases, enforce step therapy documentation requirement: verify member has failed, contraindication, or intolerance to Remicade, Inflectra, Infliximab, or Simponi Aria before authorization (exception: renewal within 365 days). For all indications, billing team must verify age requirements are met (18+ years for rheumatoid arthritis and giant cell arteritis; 2+ years for juvenile arthritis and CRS) and confirm no concurrent biologic therapy is present (Cosentyx, Enbrel, adalimumab products, Kevzara, Remicade). Add prior auth denial rules to system: automatic rejection if combination biologic therapy identified or experimental indication. Claims submitted without prior authorization or failing to meet clinical criteria will be denied. Before January 15, 2026, audit recent tocilizumab claims for compliance with new revision requirements and resubmit any that lacked proper prior auth documentation.