Tocilizumab (CPB 0799, reviewed 2026-06-30)

By 2026-06-30: (1) Billing team must implement mandatory precertification workflow for ALL tocilizumab products (Actemra, Tyenne, Avtozma, Tofidence) before claims submission. (2) Update billing system to route tocilizumab requests to precertification department with contact numbers: (866) 752-7021 (phone) or (888) 267-3277 (fax). (3) Providers must document medical necessity based on specific criteria: for RA—biomarker testing (RF, anti-CCP, CRP/ESR) and prior biologic use; for JIA—inadequate response to conventional synthetic drugs or NSAIDs with risk factors; for GCA—temporal artery biopsy or imaging plus acute-phase reactant elevation; for SSc-ILD—HRCT confirmation; for oncology indications—prior treatment failure or specific viral/disease status. (4) Verify prescriber specialty matches indication requirements (rheumatologist for RA/JIA/GCA/PMR; oncologist/hematologist for cancer-related conditions). (5) For IV tocilizumab infusions, apply Site of Care Utilization Management Policy per Aetna's specialty drug infusion guidelines. (6) Establish continuation-of-therapy criteria tracking: document baseline disease activity measurements and demonstrate at least 20% improvement for approval renewal. Failure to obtain precertification or meet documented criteria will result in claim denials.