Medicare AdvantageCoverageMedium impact
MA08.045o, Tocilizumab and Related Biosimilars for Intravenous Infusion and Subcutaneous Injection
Independence Blue Cross·Rheumatology, Oncology, Internal Medicine +1 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
Medicare Advantage plans have updated their coverage and medical necessity criteria for tocilizumab (Actemra) and related biosimilar drugs used for intravenous infusion and subcutaneous injection. This affects reimbursement requirements for these specialty medications commonly used to treat rheumatoid arthritis and other autoimmune conditions.
Action Required
Before January 1, 2026: Billing team must review updated medical necessity criteria for tocilizumab and biosimilar claims. Update prior authorization workflows and ensure providers document required medical necessity criteria for Medicare Advantage patients receiving these infusions or injections. Verify current formulary status and coverage requirements with each Medicare Advantage plan.