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Medicare AdvantagePrior AuthMedium impact

Tyenne (tocilizumab) subcutaneous (Revised)

Humana·Rheumatology, Internal Medicine, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 23, 2026
Days to comply
—

Summary

This is a revised Medicare Advantage prior authorization policy for Tyenne (tocilizumab) subcutaneous covering four indications: moderately to severely active rheumatoid arthritis (requires age ≥18 and prior therapy/contraindication/intolerance with two of three agents), systemic juvenile idiopathic arthritis (age ≥2), polyarticular juvenile idiopathic arthritis (age ≥2, with prior therapy requirement), and giant cell arteritis (age ≥18, with Rinvoq prior therapy requirement). The policy includes boxed warnings regarding serious infections, TB testing, GI perforation risk, and lab monitoring requirements.

Action Required

Action needed
Before January 1, 2026: Billing team must update prior authorization workflows in billing system to require PA for all Tyenne (tocilizumab) subcutaneous claims (both autoinjector pen and syringe formulations) under Medicare Advantage plans. For each indication, ensure clinical staff verify the applicable criteria: (1) For RA—document diagnosis of moderate-to-severe RA, member age ≥18, and evidence of prior therapy/contraindication/intolerance with at least two of: adalimumab-adbm, adalimumab-adaz, Enbrel, or Rinvoq; (2) For SJIA—document active SJIA diagnosis and age ≥2 years; (3) For Polyarticular JIA—document diagnosis, age ≥2, and prior therapy/contraindication/intolerance with two of the same agents as RA; (4) For Giant Cell Arteritis—document GCA diagnosis, age ≥18, and prior therapy/contraindication/intolerance with Rinvoq. Clinical staff should also verify TB testing status and monitor lab values (ANC ≥2000/mm³, platelets ≥100,000/mm³, ALT/AST ≤1.5x ULN) before claim submission. Update PA submission templates to require documentation of these criteria. Providers must include prior auth approval before dispensing. Failure to obtain prior authorization will result in claim denials.

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