HCPCS
J3262
1 billing unit = 1 mg
MUE 800 units/day for J3262
Actemra and the tocilizumab product family
Two biosimilars price alongside brand Actemra this quarter, and three other infused biologics sit in the same step-therapy corpus as alternatives. ASP comparison lives in Current Actemra pricing.
| Brand | HCPCS | Manufacturer | Generic |
|---|---|---|---|
| Actemra (IV) (this page) | J3262 | Genentech | tocilizumab |
| Tofidence | Q5133 | Biogen | tocilizumab-bavi |
| Tyenne | Q5135 | Fresenius Kabi | tocilizumab-aazg |
| Orencia (IV) | J0129 | Bristol Myers Squibb | abatacept |
| Remicade | J1745 | Janssen | infliximab |
| Simponi Aria | J1602 | Janssen | golimumab |
A third biosimilar, Avtozma (Q5156), appears in payer preferred lists but carries no ASP rate this quarter. Remicade, Orencia (IV) and Simponi Aria are not tocilizumab biosimilars; they are alternative infused biologics some payers require a patient to fail first.
Thirteen payers name a preferred tocilizumab product. Independence, Wellmark and BCBS NE steer to biosimilar Tyenne over branded Actemra; BCBS AR lists all four products preferred; BCBS SC reverses the pattern, keeping Actemra IV preferred while Tofidence IV and Tyenne IV are non-preferred.
Actemra's boxed warning, dose, vial sizes and administration coding are covered in full below; see Actemra dosing.
Actemra dosing
Every indication is dosed per kilogram of body weight by IV infusion over 60 minutes; the label caps RA, CRS and COVID-19 at 800 mg per infusion and GCA at 600 mg.
Boxed warning: serious infections. Patients treated with Actemra are at increased risk for developing serious infections that may lead to hospitalization or death; most patients who developed these infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids. If a serious infection develops, Actemra is interrupted until the infection is controlled.
| Indication | Starting dose | Continuing dose | Notes |
|---|---|---|---|
| Rheumatoid arthritis (adult) | 4 mg/kg IV every 4 weeks as the starting dose | 8 mg/kg (up to 800 mg) q4wk thereafter | The worked example on these pages: 8 mg/kg for 80 kg is 640 mg = 640 units of J3262 from one 400 mg and three 80 mg vials, no waste (JZ), 96365 alone. The 4 mg/kg starting dose for the same patient is 320 mg = 320 units (four 80 mg vials). The increase from 4 mg/kg to 8 mg/kg is based on clinical response; doses above 800 mg per infusion are not recommended. |
| Giant cell arteritis (adult) | 6 mg/kg IV every 4 weeks, with a tapering course of glucocorticoids | 6 mg/kg (up to 600 mg) q4wk thereafter | 6 mg/kg for 80 kg is 480 mg = 480 units from one 400 mg and one 80 mg vial, no waste. The label does not recommend GCA doses above 600 mg per infusion, so any patient over 100 kg is capped at 600 units. |
| Polyarticular JIA, under 30 kg (2 years and older) | 10 mg/kg IV every 4 weeks from the first infusion | 10 mg/kg q4wk thereafter | Diluted to 50 mL under 30 kg (label 2.9). A 20 kg child receives 200 mg = 200 units from one 200 mg vial, no waste. |
| Polyarticular JIA, 30 kg and over | 8 mg/kg IV every 4 weeks from the first infusion | 8 mg/kg q4wk thereafter | The same 8 mg/kg as the adult RA dose; the label states no ceiling for pJIA, but the J3262 MUE is 800 units a day and no payer quantity limit on file allows more than 800 mg every 4 weeks (BCBS Kansas, Centene), so the calculators on these pages cap 8 mg/kg at 800 mg. |
| Systemic JIA, under 30 kg (2 years and older) | 12 mg/kg IV every 2 weeks from the first infusion | 12 mg/kg q2wk thereafter | Every 2 weeks, twice the pJIA frequency: 26 infusions a year. A 20 kg child receives 240 mg = 240 units from three 80 mg vials, no waste. |
| Systemic JIA, 30 kg and over | 8 mg/kg IV every 2 weeks from the first infusion | 8 mg/kg q2wk thereafter | Every 2 weeks (BCBS Kansas: the dosing interval is every 2 weeks for sJIA). A 40 kg patient receives 320 mg = 320 units from four 80 mg vials, no waste. |
| Cytokine release syndrome after CAR T-cell therapy (2 years and older) | One 60-minute infusion, alone or with corticosteroids (IV only) | A single infusion, repeated up to 3 more times at least 8 hours apart | IV only (subcutaneous Actemra is not approved for CRS). Payers authorise a course of at most 4 doses (Centene: does not exceed 800 mg per infusion for up to 4 total doses; Regence: up to 4 infusions); HMHS calls more than four courses in six months experimental. |
| COVID-19, hospitalized on systemic corticosteroids (2 years and older) | One 60-minute infusion (IV only) | A single infusion, repeated once at least 8 hours later if there is no improvement | Requires systemic corticosteroids and supplemental oxygen, non-invasive or invasive ventilation, or ECMO (label 1.7). The lower starting thresholds apply: ANC 1,000, platelets 50,000, ALT or AST 10 times ULN, and no latent TB test is required. An inpatient claim, so the hospital's DRG usually absorbs it; 12 of 29 payers carry a COVID-19 rule. |
Pretreatment workup
Test for latent tuberculosis before the first infusion, except in COVID-19; a positive result is treated before starting. Do not start below an ANC of 2,000 per mm³, platelets below 100,000 per mm³, or ALT or AST above 1.5 times the upper limit of normal; the COVID-19 thresholds are lower, 1,000, 50,000 and 10 times ULN. Do not give during an active infection, including a localized one.
Duration of therapy
RA, GCA, pJIA and sJIA treatment is open-ended once a response is established: the label sets no stopping point, so payers reauthorize on documented response and on a calendar, typically 12 months. CRS and COVID-19 are single-episode courses of one to four infusions over a few days, never a maintenance schedule.
Subcutaneous route
The label also lists a subcutaneous 162 mg prefilled syringe or ACTPen autoinjector regimen for RA, GCA, pJIA and sJIA. Both are pharmacy-benefit products, not a buy-and-bill claim, and neither is approved for CRS or COVID-19.
Need the billing units for a patient? Convert dose to J3262 billing units →
Actemra billing reference
HCPCS
J3262: 1 mg per billing unit. MUE 800 units per day, the 800 mg label ceiling for RA, CRS and COVID-19.
NDCs
Three vial sizes, Genentech labeler 50242. Pad to 11 digits with a leading zero in the 3-digit product segment for CMS-1500 Box 24A.
| NDC (10-digit) | NDC (11-digit, claim form) | Package |
|---|---|---|
50242-135-01 | 50242-0135-01 | 80 mg/4 mL single-dose vial |
50242-136-01 | 50242-0136-01 | 200 mg/10 mL single-dose vial |
50242-137-01 | 50242-0137-01 | 400 mg/20 mL single-dose vial |
11-digit NDC required on most claim forms. Use the
N4 qualifier in CMS-1500 Box 24A shaded area with unit of measure and quantity actually drawn from the vial.
Administration
Actemra's 60-minute infusion is billed with 96365 alone. 96413 and 96415, CPT's chemotherapy administration codes, are the wrong family for a non-oncology monoclonal antibody.
| CPT | Description | Use for |
|---|---|---|
96365 | Intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour | The Actemra infusion ($67.14, Medicare PFS national non-facility, 2026) |
96366 | Intravenous infusion, for therapy, prophylaxis or diagnosis; each additional hour | Only when the infusion runs more than 30 minutes past the first hour, past 90 minutes total ($21.38, Medicare PFS national non-facility, 2026) |
96413 | Chemotherapy administration, IV infusion technique; up to 1 hour | Wrong family for Actemra: reserved for chemotherapy, not a non-oncology monoclonal antibody |
Modifiers
JZ: required when no drug is discarded. JW: required for documented waste. The calculators on these pages draw whichever combination of 80 mg, 200 mg and 400 mg vials wastes the least, which for most mg/kg doses at the 80 kg reference weight wastes nothing.
Effective July 1, 2023, CMS requires JZ on every no-waste claim and JW on a separate line for documented waste. The 640 mg RA maintenance dose (8 mg/kg) draws one 400 mg vial and three 80 mg vials, no waste, JZ; the 320 mg starting dose draws four 80 mg vials, no waste; the 480 mg GCA dose draws one 400 mg and one 80 mg vial, no waste. The example claim above draws the same 640 mg from two 400 mg vials instead, wasting 160 mg on a JW line — a different, equally legitimate fill.
| Weight | Dose | Vial draw | Administered | Waste / modifier |
|---|---|---|---|---|
| 80 kg | 320 mg (RA starting, 4 mg/kg) | four 80 mg vials | 320 mg | None, JZ |
| 80 kg | 480 mg (GCA, 6 mg/kg) | one 400 mg + one 80 mg vial | 480 mg | None, JZ |
| 80 kg | 640 mg (RA maintenance, 8 mg/kg) | one 400 mg + three 80 mg vials | 640 mg | None, JZ |
Claim form
CMS-1500 / 837P (physician office, AIC; POS 11/49) field map for a J3262 claim.
| Information | CMS-1500 box | Notes |
|---|---|---|
| NDC qualifier + 11-digit NDC + UoM + qty | 24A shaded area | Format: N4 qualifier + 11-digit NDC + UN + quantity drawn |
| HCPCS J3262 (administered; JZ only if no waste) | 24D (drug line) | Administered units, per MAC rounding |
| HCPCS J3262 + JW (when waste) | 24D (separate line) | Discarded units, per MAC rounding |
| Drug units | 24G | Administered + waste split across two lines, same DOS |
| CPT 96365 | 24D (admin line) | 1 unit for the initial hour; add 96366 only past 90 minutes |
| ICD-10 | 21 | M06.9 (rheumatoid arthritis), or the code matching the treated indication — see ICD-10 codes by indication |
| NPI | 17b / 24J / 33a | Rendering and billing provider NPI |
| PA number (when required) | 23 | Required by most commercial payers in 2026 |
Actemra coverage
- 27 of 29 commercial payer policy sets require prior authorization; 2 do not say clearly, so confirm those on the call
- 13 name a preferred tocilizumab product
- Requirements vary by diagnosis, payer and site of care
- A conventional DMARD trial is the recurring prerequisite for RA; a systemic corticosteroid trial for GCA; an NSAID or corticosteroid trial for sJIA
- Site of care review applies at 17 of 29 payers, across 22 rules,, steering the infusion toward an office, infusion center or the patient's home
- BCBS MA and BCBS MS are the only two payers that do not require another product tried first
ICD-10 codes by indication
Six FDA-indicated diagnoses, each mapped to its own dxKey in the payer corpus.
| Indication | ICD-10 | Payers matching this dxKey |
|---|---|---|
| Rheumatoid arthritis | M06.9 | 27 of 29 |
| Giant cell arteritis | M31.6 | 27 of 29 |
| Polyarticular JIA | M08.00 | 26 of 29 |
| Systemic JIA | M08.20 | 25 of 29 |
| Cytokine release syndrome | D89.83 | 25 of 29 |
| COVID-19 (hospitalized) | U07.1 | 12 of 29 |
Prior authorization and prerequisites
27 of 29 commercial payers require prior authorization. Rule mix across the 673-rule corpus: clinical prerequisite 350, covered indication 155, dosing 37, prior authorization 32, site of care 22, quantity limit 22, preferred product 14, step therapy 12, contraindication/exclusion 10, reauthorization 8, step external 7, combination rule 2, continuation of therapy 2.
Quantity limits, quoted verbatim: BCBS KS, "the dose should not exceed 800 mg every 28 days" (RA); Centene, "IV: 800 mg every 4 weeks" (RA); BCBS MN, "Doses exceeding 600 mg per infusion are not recommended" (the label's GCA ceiling, untagged by the payer).
Reauthorization, quoted verbatim: BCBS MI, "Clinical documentation must be provided to confirm that current criteria are met and that the medication is providing clinical benefit"; Capital Blue, "Prior authorization validity may be renewed every 12 months (365 days) thereafter…"
Site of care / POS
Payer site-of-care UM decides the infusion setting: office (POS 11), AIC (POS 49), or hospital outpatient (POS 22 on-campus, 19 off-campus).
| Setting | POS | Claim form | Electronic | Typical use |
|---|---|---|---|---|
| Physician office / infusion suite | 11 | CMS-1500 | 837P | Most maintenance doses |
| Ambulatory infusion center (AIC) | 49 | CMS-1500 | 837P | Maintenance post site-of-care steering |
| On-campus hospital outpatient | 22 | UB-04 / CMS-1450 | 837I | First dose, reaction history |
| Off-campus hospital outpatient | 19 | UB-04 / CMS-1450 | 837I | First dose at off-campus HOPD |
| Patient home | 12 | CMS-1500 | 837P | Home infusion permitted by some payers (verify) |
Check the patient's actual policy: See Actemra coverage by payer →
Current Actemra pricing
Medicare ASP+6%: $5.325 / 1 mg · $3,408.00 / 640 mg. Sequestration reduces Medicare's 80% share by 2% (effective ASP+4.3% overall). Commercial plans pay a contracted rate that differs by payer and state.
13 doses a year (8 mg/kg IV every 4 weeks for an 80 kg adult with rheumatoid arthritis, once the 4 mg/kg starting dose has been stepped up) at $3,475.14 per infusion — drug plus 96365 administration — total $45,176.82 before the sequester. That is the full annual drug-plus-administration cost for a patient staying on schedule, before benefits or assistance.
The full Medicare-basis claim for an 80 kg RA patient at 8 mg/kg: J3262 × 640 units $3,408.00 plus 96365 $67.14, total $3,475.14. Coinsurance, once the 2026 Part B deductible of $283 is met, is $695.03. Drug line only, before administration or Medigap: the 320 mg RA starting dose prices at $1,704.00; the 480 mg GCA dose at $2,556.00.
| Basis | Rate / mg | 640 mg total |
|---|---|---|
| Medicare ASP+6% (Q4 2026) | $5.325 | $3,408.00 |
| Aetna commercial median (37 of 37 payer files carry a rate) | $5.45 | $3,488.00 |
Look up commercial reimbursement →
Patient cost
The patient's actual responsibility depends on: payer allowed rate · benefits · − assistance · = patient responsibility.
Calculate a Actemra patient estimate →
Copay & financial assistance
Commercial: the ACTEMRA Co-pay Program covers drug cost only, patient may pay as little as $0 per infusion, up to $15,000 per calendar year, for eligible commercially insured patients. Uninsured: the Genentech Patient Foundation provides free drug, shipped directly to the provider with no dollar limit, for patients with household income under $150,000.
Common Actemra denials & fixes
| Denial reason | Common cause | Fix |
|---|---|---|
| Wrong admin code (96413 billed instead of 96365) | Biller defaulted to the chemotherapy family | Resubmit 96365; add 96366 only past 90 minutes total. |
| JW line missing, or JW billed on a JZ draw | Discarded drug not reported separately, or a no-waste draw mistakenly carries JW | Report discarded mg on a separate JW line only when the draw exceeds the dose; use JZ otherwise. |
| Units exceed the label ceiling or the 800-unit MUE | Dose ordered straight from weight × mg/kg past the label's 800 mg (RA/CRS/COVID-19) or 600 mg (GCA) ceiling | Confirm the ordered dose sits at or under the label ceiling before the draw; bill exactly what was administered. |
| Conventional DMARD trial not documented | PA submitted for RA without evidence of a prior csDMARD trial such as methotrexate | Submit DMARD trial dates and response, or an intolerance/contraindication note. |
| Non-preferred tocilizumab product requested | Actemra requested at a payer that designates biosimilar Tyenne preferred, such as Independence, Wellmark or BCBS NE | Document a contraindication or intolerance, or switch the request to Tyenne. |
| Reauthorization missing clinical-benefit documentation | Renewal submitted without evidence the patient is responding | Submit updated clinical notes at the reauthorization interval, typically every 12 months. |
| CRS course exceeds authorized doses | More than 4 total CRS infusions billed in a course | Confirm the dose count against the payer's 4-dose CRS limit before billing an additional infusion. |
| GCA dose billed above 600 mg | Units computed using the RA/CRS 800 mg ceiling instead of GCA's 600 mg cap | Reduce administered and billed units to the 600 mg GCA ceiling. |
| Site of care mismatch | Infusion billed at a setting the payer's site-of-care policy does not allow | Confirm the authorized site before scheduling. |
Frequently asked questions
What is the J code for Actemra?
Actemra (tocilizumab) bills under HCPCS J3262, where 1 billing unit equals 1 mg. An 80 kg adult with rheumatoid arthritis at the 8 mg/kg maintenance dose receives 640 mg, reported as 640 units of J3262 on the administered line.
Is Actemra billed with 96365 or 96413?
96365 (therapeutic infusion, initial hour). Actemra is an IL-6 receptor antagonist, not a chemotherapy agent, so 96413 and 96415, the chemotherapy codes, are the wrong family. The 60-minute infusion is 96365 alone; 96366 applies only past 90 minutes total, which a labeled Actemra infusion never reaches.
How many units of Actemra does an 80 kg patient need?
At 8 mg/kg, an 80 kg patient receives 640 mg, billed as 640 units of J3262 (1 unit = 1 mg). The least-waste draw pulls one 400 mg and three 80 mg vials, covering the dose exactly with nothing discarded, so the line carries JZ.
What is the dosing for tocilizumab by indication?
Tocilizumab is dosed per kilogram of body weight for every indication, with an 80 kg adult as the reference weight; RA, CRS and COVID-19 cap at 800 mg per infusion and GCA at 600 mg, and the subcutaneous route is excluded here as a pharmacy-benefit product, not a buy-and-bill claim:
- Rheumatoid arthritis = 8 mg/kg (up to 800 mg) every 4 weeks alone or with methotrexate or other non-biologic DMARDs (the increase from 4 mg/kg to 8 mg/kg is based on clinical response; doses above 800 mg per infusion are not recommended)
- Giant cell arteritis = 6 mg/kg (up to 600 mg) every 4 weeks with tapering glucocorticoids, then alone once glucocorticoids are discontinued
- Polyarticular JIA under 30 kg = 10 mg/kg every 4 weeks alone or with methotrexate
- Polyarticular JIA at 30 kg and over = 8 mg/kg every 4 weeks alone or with methotrexate
- Systemic JIA under 30 kg = 12 mg/kg every 2 weeks alone or with methotrexate
- Systemic JIA at 30 kg and over = 8 mg/kg every 2 weeks alone or with methotrexate
- Cytokine release syndrome = 12 mg/kg under 30 kg or 8 mg/kg (up to 800 mg) at 30 kg and over as one infusion, then up to 3 more doses at least 8 hours apart if CRS does not improve, with no scheduled dosing
- COVID-19 = 12 mg/kg under 30 kg or 8 mg/kg (up to 800 mg) at 30 kg and over as one infusion, then one more infusion at least 8 hours later if signs or symptoms worsen or do not improve, with no scheduled dosing
How often is Actemra given?
Every 4 weeks for RA (starting 4 mg/kg, stepping to 8), GCA and polyarticular JIA; every 2 weeks for systemic JIA, at any weight. CRS and COVID-19 are single infusions, not maintenance schedules: repeated only if the patient does not improve, up to 3 more CRS doses or 1 more COVID-19 dose at least 8 hours apart.
How is Actemra waste billed?
Discarded drug from a single-dose vial goes on a separate J3262 line with modifier JW; a dose with nothing discarded takes JZ instead. The least-waste draw for 640 mg (80 kg, 8 mg/kg) takes one 400 mg and three 80 mg vials, no waste. A two-vial draw of two 400 mg vials also covers 640 mg but discards 160 mg on a JW line; both are legitimate claims drawn differently.
Does Actemra require prior authorization?
Yes, at 27 of 29 payers in the tocilizumab corpus. Most require a conventional DMARD first for rheumatoid arthritis, a systemic corticosteroid first for giant cell arteritis, and an NSAID or corticosteroid first for systemic JIA; 13 payers name a preferred tocilizumab product, and renewal typically requires documentation of response every 12 months.
What changes on the claim when a tocilizumab biosimilar (Tyenne, Tofidence or Avtozma) replaces Actemra?
The HCPCS code changes: Tofidence bills Q5133 and Tyenne Q5135, both per 1 mg like Actemra's J3262; Avtozma bills Q5156, which has no ASP row this quarter, and the price changes too. Actemra's Q4 2026 ASP is $5.325 per mg against Tyenne's $4.370, the gap that gives payers a reason to steer. Independence, Wellmark and BCBS NE name Tyenne preferred; Independence requires a documented contraindication or intolerance, and Wellmark a documented intolerable adverse event with Tyenne, before Actemra is approved; BCBS AR lists all four products preferred, and BCBS SC reverses the pattern, keeping Actemra IV preferred while Tofidence IV and Tyenne IV are non-preferred.
Sources
- FDA label (DailyMed), ACTEMRA (tocilizumab), revised 08/2025
- CMS, Medicare Part B Drug ASP Pricing File, Q4 2026
- CMS, Physician Fee Schedule Look-Up Tool
- Genentech patient support, ACTEMRA Co-pay Program and Genentech Patient Foundation
- 29 commercial payer policies, current as of Aug 2026
Dataset dates: pricing Q4 2026 · payer policies Oct 2026 · assistance Sep 2026.
Reviewed September 21, 2026 by Erin Rose, CareCost Estimate founder. Methodology →