Does J3262 require prior authorization?

Yes, J3262 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J3262?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Backwork Sign up free

`J3262`, Injection, tocilizumab, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For initial authorization: documentation of diagnosis matching one of the listed FDA-approved indications or off-label compendial uses.
Age documentation as specified per indication (e.g., RA and GCA and adult-onset Still's disease and PMR and immunotherapy-related toxicities and GVHD: Is 18 years of age or older; pJIA and sJIA: Is 2 years of age or older).
Rheumatoid Arthritis: documentation of a 3-month trial of at least one biologic agent OR at least one conventional synthetic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine).
pJIA: documentation of at least one other systemic therapy tried (e.g., etanercept, adalimumab, methotrexate, sulfasalazine, leflunomide, or NSAID) OR documentation that tocilizumab will be started concurrently with methotrexate, leflunomide, or sulfasalazine OR documentation of absolute contraindication to methotrexate/leflunomide/sulfasalazine OR documentation of aggressive disease.
GCA: documentation of trial or current use of a systemic corticosteroid (e.g., prednisone) unless contraindicated.
PMR: documentation of a trial of one systemic corticosteroid (e.g., prednisone).

Key Coverage Criteria

Rheumatoid arthritis (RA)
Polyarticular juvenile idiopathic arthritis (pJIA)
Systemic juvenile idiopathic arthritis (sJIA)
Giant cell arteritis (GCA)
Still's disease, adult onset
Polymyalgia rheumatica (PMR)

20 Active Policies

ARKBLUE-TOCILIZUMAB-E-G-ACTEMRA-AND-BIOSIMILARS-418D920180, Tocilizumab (e.g., Actemra) and Biosimilars

POINT32HEALTH-PMNG-24496, Actemra (tocilizumab) Subcutaneous

MULTI

BCBSND-TOCILIZUMAB-ACTEMRA-B8E2825C1A, Tocilizumab Actemra

BCBSNJ-DRUGS-076-9B5D3DEC61, Tocilizumab (Actemra)

MODA-TOCILIZUMAB-E794EF6480, Tocilizumab: Actemra; Tofidence; Tyenne; Avtozma; Tocilizumab-anoh§; Tocilizumab-aazg§

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

BCBSIL-RX501.115, Tocilizumab and Associated Biosimilar(s)

BCBSMT-RX502.061, Oncology Medications

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSMT-RX501.115, Tocilizumab and Associated Biosimilar(s)

BCBSNM-RX502.061, Oncology Medications

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf

BCBSOK-RX502.061, Oncology Medications

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.115, Tocilizumab and Associated Biosimilar(s)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-tocilizumab, Tocilizumab Injection for Intravenous Infusion

SUREST-POL-SUREST-tocilizumab, Tocilizumab Injection for Intravenous Infusion

EVICORE-MEDICAL_DRUG-41AC5A9A3ABC, Tocilizumab Intravenous (Actemra, Avtozma, Tyenne, Tofidence) non-oncology

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J3262 Sign up free

J3262, Injection, tocilizumab, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For initial authorization: documentation of diagnosis matching one of the listed FDA-approved indications or off-label compendial uses.
Age documentation as specified per indication (e.g., RA and GCA and adult-onset Still's disease and PMR and immunotherapy-related toxicities and GVHD: Is 18 years of age or older; pJIA and sJIA: Is 2 years of age or older).
Rheumatoid Arthritis: documentation of a 3-month trial of at least one biologic agent OR at least one conventional synthetic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine).
pJIA: documentation of at least one other systemic therapy tried (e.g., etanercept, adalimumab, methotrexate, sulfasalazine, leflunomide, or NSAID) OR documentation that tocilizumab will be started concurrently with methotrexate, leflunomide, or sulfasalazine OR documentation of absolute contraindication to methotrexate/leflunomide/sulfasalazine OR documentation of aggressive disease.
GCA: documentation of trial or current use of a systemic corticosteroid (e.g., prednisone) unless contraindicated.
PMR: documentation of a trial of one systemic corticosteroid (e.g., prednisone).

Key Coverage Criteria

Rheumatoid arthritis (RA)
Polyarticular juvenile idiopathic arthritis (pJIA)
Systemic juvenile idiopathic arthritis (sJIA)
Giant cell arteritis (GCA)
Still's disease, adult onset
Polymyalgia rheumatica (PMR)

20 Active Policies

ARKBLUE-TOCILIZUMAB-E-G-ACTEMRA-AND-BIOSIMILARS-418D920180, Tocilizumab (e.g., Actemra) and Biosimilars

POINT32HEALTH-PMNG-24496, Actemra (tocilizumab) Subcutaneous

MULTI

BCBSND-TOCILIZUMAB-ACTEMRA-B8E2825C1A, Tocilizumab Actemra

BCBSNJ-DRUGS-076-9B5D3DEC61, Tocilizumab (Actemra)

MODA-TOCILIZUMAB-E794EF6480, Tocilizumab: Actemra; Tofidence; Tyenne; Avtozma; Tocilizumab-anoh§; Tocilizumab-aazg§

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

BCBSIL-RX501.115, Tocilizumab and Associated Biosimilar(s)

BCBSMT-RX502.061, Oncology Medications

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSMT-RX501.115, Tocilizumab and Associated Biosimilar(s)

BCBSNM-RX502.061, Oncology Medications

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf

BCBSOK-RX502.061, Oncology Medications

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.115, Tocilizumab and Associated Biosimilar(s)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-tocilizumab, Tocilizumab Injection for Intravenous Infusion

SUREST-POL-SUREST-tocilizumab, Tocilizumab Injection for Intravenous Infusion

EVICORE-MEDICAL_DRUG-41AC5A9A3ABC, Tocilizumab Intravenous (Actemra, Avtozma, Tyenne, Tofidence) non-oncology

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J3262 Sign up free

`J3262`, Injection, tocilizumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3262`, Injection, tocilizumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3262, Injection, tocilizumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3262, Injection, tocilizumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3262`, Injection, tocilizumab, 1 mg

`J3262`, Injection, tocilizumab, 1 mg