Actemra family (tocilizumab) — J3262 + biosimilars

Tocilizumab biosimilars — verify HCPCS at billing time CMS HCPCS + FDA verified May 2026

Tofidence (Q5135) is permanent; Tyenne and Avtozma are newer and may temporarily bill under NOC codes (J3490 / C9399) until permanent Q-codes are assigned.

All tocilizumab products carry the same FDA boxed warning for serious infections (TB, invasive fungal, bacterial, viral, opportunistic). TB screening pre-therapy is required regardless of brand. Hepatitis B serology is recommended due to HBV reactivation risk.

IV vs. SC channel — J3262 covers IV only FDA labels verified 2025–2026

The Actemra subcutaneous prefilled syringe and ACTPen are not billed under J3262 — they go through specialty pharmacy under the pharmacy benefit by NDC.

Dosing matrix per FDA-approved indication FDA Actemra label + ACR / NCCN / NIH guidelines

Six approved indications, each with its own dosing logic. All weight-based regimens trigger partial-vial waste — expect JW.

NDC reference — Actemra IV vials FDA NDC Directory verified May 2026

Pad to 11 digits with a leading zero in the middle segment for CMS-1500 Box 24A.

Actemra (J3262) — Genentech labeler 50242

Tofidence (Q5135) — Biogen / Bio-Thera

Verify current Tofidence labeler and packaging NDCs at billing time. Strengths mirror Actemra (80, 200, 400 mg SDV at 20 mg/mL).

Tyenne — Fresenius Kabi

Newer biosimilar. Verify HCPCS (may be NOC initially) and NDCs at billing time.

Avtozma — Celltrion

Newest biosimilar (FDA approved 2024–2025). Verify HCPCS and NDCs at billing time.

Administration codes CPT verified May 2026

Tocilizumab is a non-cytotoxic biologic IL-6 receptor antagonist. Use therapeutic infusion codes (96365/96366), not chemotherapy codes (96413/96415).

First-dose administration setting

Tocilizumab does not carry the same hospital-outpatient mandate that some IL-6 / monoclonal-antibody infusions do. Most RA, PJIA, SJIA, and GCA patients receive Actemra in an office (POS 11) or ambulatory infusion center (POS 49). CRS is by definition inpatient (POS 21 or hospital outpatient at the CAR-T center). Hospitalized COVID-19 dosing is inpatient.

Modifiers — JZ, JW, and weight-based waste CMS verified May 2026

All Actemra vials are single-dose. Weight-based dosing means partial-vial waste is the rule, not the exception.

JZ — required when no drug discarded

Effective July 1, 2023, CMS requires the JZ modifier on all single-dose container claims when no drug is discarded. For tocilizumab, JZ would apply only when the calculated dose exactly matches the vial set drawn (rare with weight-based dosing). The 800 mg cap (CRS / COVID / max RA escalation) hits exactly two 400 mg vials — a JZ scenario.

JW — required for documented waste of unused single-dose-vial drug

Because almost every tocilizumab indication uses weight-based mg/kg dosing (4, 8, 10, or 12 mg/kg), the calculated dose rarely matches an integer combination of 80, 200, and 400 mg vials. CMS requires the JW modifier on a separate claim line for the discarded units (rounded per CMS rules), with wastage documented in the medical record. Bill administered units (with JZ) and discarded units (with JW) on two separate lines, same date of service.

Apply each MAC’s rounding convention. Vial selection should minimize total waste and document why the chosen combination was used. Refer to your local MAC billing article for the exact rounding rule.

JG / TB — 340B drug pricing

Hospitals that purchase tocilizumab through 340B and bill Medicare report the JG modifier (acute-care hospitals) or TB modifier (rural sole community / critical-access hospitals), per CMS guidance.

Modifier 25 — same-day E/M

Append modifier 25 to the same-day E/M code if a significant, separately identifiable evaluation occurred (DAS-28 reassessment for next-cycle decision in RA, GCA flare reassessment, etc.). Routine pre-infusion check-in is bundled.

ICD-10-CM diagnosis codes FY2026 verified May 2026

Use the most specific code supported by chart documentation. Each FDA indication has a distinct code family.

Site of care & place of service Verified May 2026

RA, PJIA, SJIA, GCA infusions move easily to office or AIC. CRS and COVID dosing is inpatient.

Payer site-of-care steering

UnitedHealthcare, Aetna, Cigna, and most BCBS plans apply site-of-care UM to specialty infusion drugs. For chronic Actemra (RA, PJIA, GCA), payers typically require dosing at office (POS 11) or in-network AIC (POS 49) where facility fees are lower. The 60-minute Actemra infusion fits these sites cleanly. Hospital outpatient (POS 19/22) is generally limited to first-dose with reaction history or pediatric SJIA scenarios where a tertiary-center setting is medically necessary.

Claim form field mapping Genentech billing PDF + payer guides

CMS-1500 / 837P (physician office, AIC; POS 11/49) example for a 280 mg RA dose of J3262.

Source: Genentech Actemra Billing & Coding Brochure; payer-specific medical policy documents.

Payer policy snapshot — tocilizumab UM 2026 Reviewed May 2026

RA new starts almost universally require step therapy from a TNF inhibitor. CRS and COVID inpatient indications generally bypass PA because the drug is hospital-billed under DRG.

2026 trend — biosimilar steerage

Tofidence (Q5135) launched in 2024 as the first tocilizumab biosimilar; Tyenne and Avtozma have since added competition. CVS Cordavis and ESI Quallent — the private-label biosimilar arms of CVS Health and Express Scripts — are increasingly steering practices to biosimilar tocilizumab. Expect formal biosimilar-preferred designations from major payers during 2026 as competition matures, mirroring the rituximab and trastuzumab biosimilar transitions of 2023–2025.

What to document for step-therapy approval

• TNFi tried (drug name, HCPCS / NDC, dates of administration, dose)
• Duration of trial (most policies: at least 3 months adequate dosing)
• Documented inadequate response, intolerance, or contraindication (with objective measures: DAS-28, CDAI, CRP, ESR)
• For GCA: glucocorticoid taper documentation; tocilizumab is steroid-sparing
• For SJIA / PJIA: pediatric rheumatology consult notes, growth parameters, joint count

Medicare reimbursement CMS Q2 2026 (live)

Quarterly ASP from CMS Part B Drug Pricing File. J3262 refreshes every quarter; biosimilar ASPs (where assigned) refresh on the same cycle.

Dose-band reimbursement at Q2 2026 ASP+6%

Annual reimbursement — chronic RA

At 4 mg/kg q4wk for a 70 kg patient (280 mg / dose, 13 doses / year), annual J3262 reimbursement is approximately $20,129 at Q2 2026 ASP+6%. Escalated 8 mg/kg dosing roughly doubles this. Biosimilar dispense (Tofidence Q5135 or other) is generally lower — verify current biosimilar ASP at billing time.

Coverage

No NCD specific to tocilizumab. Each MAC publishes a billing & coding article covering the drug with covered ICD-10 ranges per indication. All MACs cover J3262 for FDA-approved indications. CRS and COVID-19 inpatient dosing is bundled into the DRG — no separate Part B claim. Hospitalized COVID-19 use follows NIH treatment guidelines (8 mg/kg for hospitalized adults requiring O₂ / MV / ECMO with corticosteroids).

Canonical code source: CMS HCPCS quarterly update file.

Patient assistance — per manufacturer Manufacturer sites verified May 2026

• Actemra (J3262, Genentech):
  • Genentech Access Solutions: 1-866-422-2377 — benefits investigation, PA support, appeals.
  • Actemra Co-pay Card: eligible commercially-insured patients, up to $25,000/year.
  • Genentech Patient Foundation: free drug for uninsured/underinsured (income-eligible).
  • Independent foundations (PAN, HealthWell) for Medicare patients — verify open funds quarterly.
• Tofidence (Q5135, Biogen): Biogen Patient Support — benefits investigation, copay support for eligible commercially-insured patients, free-drug pathway for qualifying uninsured patients.
• Tyenne (Fresenius Kabi): Fresenius Kabi Patient Support — manufacturer support program for eligible patients.
• Avtozma (Celltrion): Celltrion patient support — verify program details at billing time as program is newer.

Boxed warning & ongoing monitoring FDA Actemra label verified 2025–2026

Pre-therapy screening

• TB screening required: interferon-gamma release assay (IGRA, e.g., QuantiFERON-TB Gold) or tuberculin skin test (PPD) before initiating tocilizumab.
• Treat latent TB before starting Actemra. Continue TB-directed therapy concurrent with tocilizumab if active TB diagnosed during screening.
• Hepatitis B serology: screen HBsAg and anti-HBc; consult hepatology for HBV-positive or occult-infected patients prior to starting due to HBV reactivation risk.
• Lipid panel: baseline lipids; tocilizumab causes lipid elevations (total cholesterol, LDL, triglycerides).
• CBC + LFTs: baseline neutrophil count, platelets, ALT, AST, total bilirubin.

Other significant warnings & precautions

• GI perforation: reported in tocilizumab-treated patients, especially with diverticulitis history. Use caution and educate patients to report acute abdominal pain.
• Hepatotoxicity: serious hepatic injury (some fatal, requiring transplant) reported. Monitor LFTs at baseline and every 4–8 weeks.
• Laboratory abnormalities: neutropenia, thrombocytopenia, transaminitis, lipid elevations — monitor q4–8wk per label. Hold dose if ANC < 1,000 / mm³, platelets < 100,000 / mm³, or ALT/AST > 5× ULN.
• Hypersensitivity / anaphylaxis: reported with IV and SC. Have resuscitation equipment available.
• Demyelinating disorders: rare CNS demyelinating events reported.
• Live vaccines: avoid concurrent live vaccines.
• Pregnancy: limited data; pregnancy registry available.

Common denials & how to fix them

Frequently asked questions

What is the HCPCS code for Actemra?

Intravenous Actemra (tocilizumab) is billed as J3262 — "Injection, tocilizumab, 1 mg." One billing unit equals 1 mg of drug. Q5135 is Tofidence (tocilizumab-bavi, Biogen), the first FDA-approved tocilizumab biosimilar (effective 2024). Tyenne (tocilizumab-aazg, Fresenius Kabi) and Avtozma (tocilizumab-anoh, Celltrion) are newer biosimilars — verify their current HCPCS at billing time, as new biosimilars may temporarily use J3490 / C9399 (NOC) until permanent Q-codes are assigned. The subcutaneous Actemra prefilled syringe and ACTPen are dispensed through specialty pharmacy and are NOT billed under J3262.

How many units of J3262 do I bill for a tocilizumab dose?

J3262 uses 1 unit = 1 mg. A 4 mg/kg dose for a 70 kg RA patient = 280 mg = 280 units. An 8 mg/kg CRS dose at the 800 mg cap = 800 units. A 12 mg/kg systemic JIA dose for a 25 kg child = 300 mg = 300 units. Because dosing is weight-based for almost every indication, partial-vial waste is the rule — expect to bill JZ on the administered units and JW on a separate line for discarded units.

What administration codes apply to Actemra?

Tocilizumab is a non-cytotoxic biologic, so administration uses 96365 (therapeutic IV infusion, initial up to 1 hour) — not the chemotherapy codes 96413 / 96415. The standard Actemra IV infusion is 60 minutes, so 96366 (each additional hour) is rarely needed. Billing 96413/96415 for tocilizumab is a denial trigger and a coding compliance issue.

What is the Q2 2026 Medicare reimbursement for J3262 Actemra?

Q2 2026 ASP + 6% for J3262 (Actemra reference) is approximately $5.530 per 1 mg unit. A 4 mg/kg RA dose for a 70 kg patient (280 mg) reimburses ~$1,548. The 800 mg single-dose CRS or COVID-19 administration reimburses ~$4,424. Annual RA at q4wk dosing is ~$20,129 per 70 kg patient. Biosimilar pricing (Q5135 Tofidence and others) is generally lower — see the live snapshot.

Are Actemra biosimilars interchangeable?

Tofidence (tocilizumab-bavi, Q5135), Tyenne (tocilizumab-aazg), and Avtozma (tocilizumab-anoh) are FDA-approved biosimilars to Actemra. Each is approved separately and has its own HCPCS code (verify Tyenne and Avtozma codes at billing time — new biosimilars may temporarily use NOC codes). FDA interchangeability designation is not automatic — pharmacy/infusion-center substitution depends on FDA labeling and state law. Payers including CVS Cordavis and ESI Quallent are increasingly steering to biosimilar tocilizumab in 2026.

Is the Actemra subcutaneous form billed under J3262?

No. The Actemra subcutaneous prefilled syringe (162 mg/0.9 mL PFS) and the ACTPen autoinjector are dispensed through specialty pharmacy under the pharmacy benefit, not the medical benefit. They are billed by NDC, not by J-code, and J3262 applies only to intravenous administration. Practices providing only IV Actemra need not address the SC channel; coordination is required when patients transition from IV (often initial GCA or RA induction) to SC self-injection.

Why is TB screening required before starting Actemra?

All tocilizumab products carry an FDA boxed warning for serious infections, including TB reactivation, invasive fungal infections (candidiasis, aspergillosis), bacterial sepsis, viral infections, and other opportunistic infections. The Actemra label requires TB screening (interferon-gamma release assay or tuberculin skin test) before starting therapy. Patients with latent TB must complete treatment before initiating tocilizumab. Hepatitis B serology is also recommended due to HBV reactivation risk.

How does Actemra dosing differ across indications?

Adult RA: 4 mg/kg q4wk (may escalate to 8 mg/kg q4wk, max 800 mg). Polyarticular JIA (≥ 2 yr): 10 mg/kg q4wk if < 30 kg, 8 mg/kg q4wk if ≥ 30 kg. Systemic JIA (≥ 2 yr): 12 mg/kg q2wk if < 30 kg, 8 mg/kg q2wk if ≥ 30 kg. GCA: SC 162 mg weekly is preferred; IV q4wk is available. CRS (CAR-T cytokine release syndrome): 8 mg/kg IV (max 800 mg), may repeat q8h up to 4 doses. COVID-19 (hospitalized requiring supplemental O₂ / MV / ECMO + corticosteroids): 8 mg/kg IV (max 800 mg) single dose. SSc-ILD: generally SC; some IV use.

What payer step-therapy applies to Actemra in 2026?

Most major payers (UnitedHealthcare, Aetna, Cigna, BCBS) require prior authorization plus step therapy from a TNF inhibitor for RA new starts. Biosimilar substitution policies are emerging in 2026 — CVS Cordavis and ESI Quallent are private-label biosimilar programs that may steer to Tofidence or Tyenne. CRS and COVID-19 inpatient indications generally do not require PA because the drug is hospital-billed under the inpatient DRG. Verify each payer’s medical drug policy before scheduling chronic-use patients.

Source documents

1. AAPC — HCPCS J3262 (Actemra / tocilizumab)
   Code descriptor and crosswalk reference
2. AAPC — HCPCS Q5135 (Tofidence / tocilizumab-bavi)
   Biosimilar code descriptor (Biogen)
3. FDA Actemra (tocilizumab) label
   Reference tocilizumab prescribing information; boxed warnings; indication panel; dosing per indication
4. Genentech — Actemra prescribing information
   Full label including TB screening, hepatic monitoring, GI perforation precautions
5. Genentech — Actemra Billing & Coding resources (HCP)
   CMS-1500 field guidance; admin code clarification (96365 non-chemo)
6. Genentech Access Solutions — Actemra
   Co-pay program (up to $25,000/yr); Patient Foundation; benefits investigation; 1-866-422-2377
7. Biogen — Tofidence (tocilizumab-bavi)
   First FDA-approved tocilizumab biosimilar (Q5135); manufacturer support
8. Fresenius Kabi — Tyenne (tocilizumab-aazg)
   Tocilizumab biosimilar; verify HCPCS at billing time
9. Celltrion — Avtozma (tocilizumab-anoh)
   Tocilizumab biosimilar; verify HCPCS at billing time
10. UnitedHealthcare — Tocilizumab Commercial Medical Drug policy
    RA step therapy (TNFi); biosimilar trend; site-of-care UM
11. Aetna — Tocilizumab CPB
    Step therapy criteria; covered indications; documentation requirements
12. ACR — Rheumatoid Arthritis & JIA Treatment Guidelines
    RA, polyarticular JIA, systemic JIA treatment recommendations
13. NCCN — CAR-T Cell-Related Toxicities (Cytokine Release Syndrome)
    Tocilizumab dosing for CRS grade 2–4; repeat-dose protocol
14. NIH COVID-19 Treatment Guidelines — Tocilizumab
    Hospitalized COVID-19 dosing; eligibility (O₂/MV/ECMO + corticosteroids)
15. CMS — Medicare Part B Drug ASP Pricing File
    Q2 2026 quarterly file (J3262, Q5135)
16. CMS — HCPCS quarterly update file
    Canonical HCPCS code source for tocilizumab family
17. CMS — JW / JZ modifier guidance
    Single-dose-container waste reporting (effective 7/1/2023)

About this page

We maintain this page as a living reference for the entire tocilizumab IV family. Medicare ASP pricing for J3262 (and Q5135 Tofidence where assigned) is bound to our underlying CareCost data layer and refreshes automatically when CMS publishes new quarterly files. Coding and policy content is reviewed at least quarterly and updated whenever a manufacturer guide, FDA label, biosimilar approval, or major payer policy changes.

Found an error? Email hello@carecostestimate.com.

Refresh cadence

Reviewer

Change log

• May 2, 2026 — Initial publication of the tocilizumab IV family reference. ASP data: Q2 2026 (J3262 live; Q5135 verify). Indication coverage: RA, PJIA, SJIA, GCA, CRS (CAR-T), COVID-19 (hospitalized), SSc-ILD. Biosimilar coverage: Tofidence (Q5135) permanent; Tyenne and Avtozma flagged "verify HCPCS." Payer policies: UHC commercial, Aetna CPB, Cigna, BCBS step therapy from TNFi for RA. CVS Cordavis and ESI Quallent biosimilar steerage noted.

Methodology

Every claim on this page is sourced inline. Pricing reflects the current CMS Part B Drug ASP Pricing File for J3262 and Q5135. Payer policies are read directly from each payer’s published medical policy documents. We do not paraphrase from billing-software vendor blogs. When the FDA label and clinical guidelines provide different dosing detail (e.g., GCA preferring SC 162 mg weekly while the IV q4wk option remains available), we surface both rather than picking a side.