Does Q5156 require prior authorization?

Yes, Q5156 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5156?

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

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`Q5156`, Injection, tocilizumab-anoh (avtozma), 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).

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

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)
Still's disease, adult onset

11 Active Policies

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

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

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

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

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

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

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

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

UHC-POL-tocilizumab, Tocilizumab Injection for Intravenous Infusion

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

`Q5156`, Injection, tocilizumab-anoh (avtozma), biosimilar, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

Q5156, Injection, tocilizumab-anoh (avtozma), biosimilar, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

`Q5156`, Injection, tocilizumab-anoh (avtozma), biosimilar, 1 mg