Actemra SC — Medical Mutual

Initial criteria

• Patient has tried one systemic therapy (e.g., methotrexate, sulfasalazine, leflunomide, NSAID, or one biologic other than a tocilizumab product); OR patient will be starting Actemra SC concurrently with methotrexate, sulfasalazine, or leflunomide; OR patient has an absolute contraindication to methotrexate, sulfasalazine, or leflunomide; OR patient has aggressive disease as determined by provider; AND
• Medication is prescribed by or in consultation with a rheumatologist; AND
• Site of care medical necessity is met

Reauthorization criteria

• Patient has been established on therapy for at least 6 months; AND
• Patient experienced a beneficial clinical response assessed by objective measures OR an improvement in at least one symptom compared with baseline

Approval duration

initial: 6 months; reauth: 1 year