BlueCross BlueShield of Tennessee Medical Policy Manual

Tocilizumab (Intravenous)


50242-0135-XX Actemra 80 MG/4ML SOLN (GENENTECH)

50242-0136-XX Actemra 200 MG/10ML SOLN (GENENTECH)

50242-0137-XX Actemra 400 MG/20ML SOLN (GENENTECH)


Tocilizumab is a recombinant interleukin 6 (IL-6) receptor monoclonal antibody classified as a disease modifying antirheumatic drug.  It binds specifically to soluble and membrane-bound IL-6 receptors and has been shown to block IL-6-mediated signaling through these receptors.  IL-6 is a pro-inflammatory cytokine produced by a variety of cell types, including synovial and endothelial cells in joints affected by inflammatory processes.







Doses exceeding 800 mg per infusion are not recommended

Adult Rheumatoid Arthritis

4 mg/kg  IV every 4 weeks

May increase to 8 mg/kg every 4 weeks based on clinical response

Polyarticular Juvenile Idiopathic Arthritis

Weight ≥ 30 kg - 8 mg/kg IV every 4 weeks

Weight < 30 kg - 10 mg/kg IV every 4 weeks

Systemic Juvenile Idiopathic Arthritis

Weight ≥ 30 kg - 8 mg/kg IV every 2 weeks

Weight < 30 kg - 12 mg/kg IV every 2 weeks

Castleman’s Disease (NHL)

8 mg/kg IV every 2 weeks for 16 weeks (8 doses)

Cytokine Release Syndrome (CRS)

Weight ≥ 30 kg - 8 mg/kg IV every 8 hours, if needed, up to a maximum of 4 total doses*

Weight < 30 kg -12 mg/kg IV every 8 hours, if needed, up to a maximum of 4 total doses*

*If no clinical improvement in the signs and symptoms of CRS occurs after the first dose, up to 3 additional doses may be administered. The interval between consecutive doses should be at least 8 hours. May be used with or without corticosteroids.

Immune-Checkpoint Inhibitor Related Inflammatory Arthritis

4 mg/kg IV ONE TIME


Coverage will be provided for Castleman’s Disease for 4 months and may be renewed;

Coverage will be provided for Cytokine Release Syndrome for 4 doses only and may not be renewed;

Coverage will be provided for Immune Checkpoint Inhibitor related arthritis for 1 dose only and may not be renewed;

All other indications, coverage will be provided for 6 months and may be renewed.

Click here to view DOSAGE LIMITS


BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.


We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.


For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

No controlled studies were found in the published literature that validate the use of tocilizumab for the treatment or prevention of other conditions or diseases.


Lexi-Comp Online. (2018). AHFS DI. Tocilizumab. Retrieved November 15, 2017 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Evaluations. (2018, October). Tocilizumab. Retrieved November 20, 2018 from MICROMEDEX Healthcare Series.

National Comprehensive Cancer Network. (2018). NCCN Drugs & Biologics Compendium®. Tocilizumab. Retrieved September 17, 2018 from the National Comprehensive Cancer Network.

Ringold, S., Weiss P.F., Beukelman T., DeWitt, E.M., Ilowite, N.T., Kimura, Y., et al. (2013, October). 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. Arthritis & Rheumatism 65(10), 2499-512. Retrieved June 1, 2017 from

U. S. Food and Drug Administration. (2018, September). Center for Drug Evaluation and Research. Actemra® (tocilizumab) injection, for intravenous or subcutaneous use. Retrieved September 17, 2018 from,125472s031lbl.pdf.   




Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.



Maximum billable units per dose and over time by indication as a Medical Benefit; 1 billable unit = 1 mg


Billable Units

Interval (days)

Rheumatoid Arthritis & Polyarticular Juvenile Idiopathic Arthritis



Systemic Juvenile Idiopathic Arthritis & Castleman’s Disease (NHL)



Cytokine Release Syndrome (CRS)


1 course of therapy only

Immune Checkpoint Inhibitor Related Arthritis


1 course of therapy only