Does Q5133 require prior authorization?

Yes, Q5133 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5133?

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

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`Q5133`, Injection, tocilizumab-bavi (tofidence), biosimilar, 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.

Key Coverage Criteria

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Polyarticular juvenile idiopathic arthritis: Initial therapy requires PJIA diagnosis, FDA-labeled dosing for PJIA, not in combination with a systemic targeted immunomodulator, and initial authorization up to 12 months; continuation requires prior Tocilizumab IV, documented positive response, FDA-labeled PJIA dosing, not in combination with systemic targeted immunomodulator, up to 12 months.
Rheumatoid arthritis (RA)
Polyarticular juvenile idiopathic arthritis (pJIA)
Systemic juvenile idiopathic arthritis (sJIA)
Giant cell arteritis (GCA)

17 Active Policies

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

EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-4BC80209CCC5, Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List

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

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

UHC-POL-tocilizumab, Tocilizumab Injection for Intravenous Infusion

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

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

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

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

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

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

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

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

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

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Q5133, Injection, tocilizumab-bavi (tofidence), biosimilar, 1 mg