Page reviewed Aug 23, 2026 · from FDA-approved labeling (Drugs@FDA) — no drug-specific Medicare LCD
Quick answer
Medicare benefit
Part B (physician-administered)
FDA-indicated diagnoses
11 ICD-10 codes
Governing policy
FDA indications (no LCD)
Contractor (MAC)
Per medical necessity
Source
FDA labeling
Page reviewed
Aug 23, 2026
HCPCS codes covered:
J3262
J3262
No drug-specific Medicare coverage article exists for Actemra. Coverage is decided per medical necessity by your MAC. The FDA-approved indications below are the labeled uses Medicare generally pays for; an off-label use may be covered if supported by an approved compendium. Find your MAC by state →
What Medicare pays for Actemra (2026 Q3)
Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J3262 | Tocilizumab injection | 1 mg | $5.408 |
Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →
Actemra is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J3262) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).
Covered ICD-10 diagnoses for Actemra
The 11 FDA-approved indications for J3262, grouped by condition — filter to find a code.
Rheumatoid Arthritis — 4 diagnoses (applies to J3262)
Diseases of the musculoskeletal system & connective tissue (4)
| ICD-10 | Covered diagnosis |
|---|---|
| M05.59 | RA with rheumatoid factor, multiple sites |
| M05.79 | RA with rheumatoid factor, unspecified site |
| M06.09 | RA without rheumatoid factor, unspecified site |
| M06.9 | Rheumatoid arthritis, unspecified |
Giant Cell Arteritis — 2 diagnoses (applies to J3262)
Diseases of the musculoskeletal system & connective tissue (2)
| ICD-10 | Covered diagnosis |
|---|---|
| M31.5 | Giant cell arteritis with polymyalgia rheumatica |
| M31.6 | Other giant cell arteritis |
Juvenile Idiopathic Arthritis — 2 diagnoses (applies to J3262)
Diseases of the musculoskeletal system & connective tissue (2)
| ICD-10 | Covered diagnosis |
|---|---|
| M08.00 | Unspecified juvenile RA, unspecified site |
| M08.20 | Juvenile RA, systemic onset, unspecified site |
Cytokine Release Syndrome — 1 diagnoses (applies to J3262)
Injury, poisoning & external causes (1)
| ICD-10 | Covered diagnosis |
|---|---|
| T45.1X5A | Adverse effect of antineoplastic/immunosuppressive drugs (CRS) |
SSc-ILD — 2 diagnoses (applies to J3262)
Diseases of the respiratory system (1)
| ICD-10 | Covered diagnosis |
|---|---|
| J84.170 | Interstitial lung disease with SSc |
Diseases of the musculoskeletal system & connective tissue (1)
| ICD-10 | Covered diagnosis |
|---|---|
| M34.81 | Systemic sclerosis with lung involvement |
What commercial payers require for Actemra
Medicare Part B is only half the answer — most Actemra claims are adjudicated by a commercial plan with its own medical policy. Below is what 29 commercial payers publish for Actemra, read from each payer's own policy document. 27 of 29 that state a position require prior authorization, and 17 run a site-of-care program that can push the infusion out of the hospital outpatient setting. 13 name a preferred product you must try or fail first.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | Site of Care Utilization Management Policy applies; see Utilization Management Policy on Site of Care for Specialty Drug Infusions | 5 | 2026-06-30 |
| Anthem / Elevance policy ↗ | Required | — | — | 6 | 2024-03-01 |
| Arkansas BCBS policy ↗ | Required | J3262, Q5133, Q5135 | — | 6 | 2022-04-01 |
| BCBS Federal Employee Program policy ↗ | Required | — | — | 6 | 2025-07-01 |
| BCBS Kansas policy ↗ | Not required | — | Site-of-care program applies | 5 | — |
| BCBS Louisiana policy ↗ | Required | J3262, Q5133, Q5135 | — | 5 | 2026-01-01 |
| BCBS Massachusetts policy ↗ | Required | — | — | — | 2026-07-01 |
| BCBS Michigan policy ↗ | Required | Q5135 | Site-of-care program applies | 6 | 2026-04-16 |
| BCBS Minnesota policy ↗ | Required | — | — | 5 | 2026-03-03 |
| BCBS Mississippi policy ↗ | Required | Q5135 | — | 1 | 2025-01-01 |
| BCBS Nebraska policy ↗ | Required | Q5135 | — | 4 | 2025-11-05 |
| BCBS South Carolina policy ↗ | Required | J3262 | Site-of-care program applies | 4 | — |
| BCBS Tennessee policy ↗ | Required | Q5133 | COVID-19 managed under inpatient benefit; outpatient policy criteria do not apply | 6 | 2025-12-31 |
| Blue Shield of California policy ↗ | Required | Q5135 | preferred site of service | 6 | 2026-07-01 |
| Capital BlueCross policy ↗ | Required | — | — | 5 | 2026-03-03 |
| CareFirst BCBS policy ↗ | Required | — | — | 1 | — |
| Centene / Ambetter policy ↗ | Required | — | Site-of-care program applies | 6 | — |
| Cigna policy ↗ | Required | — | Site-of-care program applies | 5 | 2026-06-01 |
| Excellus BCBS policy ↗ | Required | — | inpatient_only | 6 | 2026-06-23 |
| Florida Blue policy ↗ | Required | Q5135 | conditional | 6 | 2026-07-01 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Required | — | Site-of-care program applies | 4 | 2026-06-15 |
| Highmark BCBS policy ↗ | Required | — | Site-of-care program applies | 5 | 2026-03-01 |
| HMSA (BCBS Hawaii) policy ↗ | Required | — | Site-of-care program applies | 6 | 2026-04-01 |
| Horizon BCBS NJ policy ↗ | Required | — | Site of Administration for Infusion and Injectable Prescription Medications; Policy #142 | 5 | 2020-09-08 |
| Independence Blue Cross policy ↗ | Not required | Q5135 | reimburse only in the most appropriate and cost-effective setting | 6 | 2026-04-01 |
| Premera Blue Cross policy ↗ | Required | — | This site is considered medically necessary when the individual has cytokine release syndrome (CRS) and all the following are met: | 3 | 2025-01-03 |
| Regence BCBS policy ↗ | Required | Q5135 | dru408; Site of care administration requirements must be met per dru408 | 5 | 2026-04-01 |
| UnitedHealthcare policy ↗ | Required | J3262, Q5156 | — | 5 | 2026-07-01 |
| Wellmark BCBS policy ↗ | Required | Q5135 | — | 6 | 2026-05-15 |
What Actemra payers put in writing
Quoted from the medical policies linked above — 24 distinct requirements across 29 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
Member cannot use the requested medication concomitantly with any other biologic drug or targeted synthetic drug.
— Aetna, BCBS Tennessee and 2 other payers policy ↗Rheumatoid arthritis, articular juvenile idiopathic arthritis, systemic juvenile idiopathic arthritis, giant cell arteritis, and polymyalgia rheumatica: rheumatologist
— Aetna, BCBS Tennessee, Wellmark BCBS policy ↗Inadequate response, intolerance, or contraindication to a 3-month trial of at least ONE conventional disease-modifying antirheumatic drugs (DMARDs)
— BCBS Federal Employee Program, BCBS Kansas, BCBS South Carolina policy ↗Member has had a documented negative tuberculosis (TB) test (which can include a tuberculosis skin test [TST] or an interferon-release assay [IGRA]) within 12 months of initiating therapy
— BCBS Tennessee, HMSA (BCBS Hawaii), Wellmark BCBS policy ↗Prescribed by or in consultation with a rheumatologist
— Blue Shield of California, Centene / Ambetter, UnitedHealthcare policy ↗Member has had an inadequate response to methotrexate or another conventional synthetic drug (e.g., leflunomide, sulfasalazine, hydroxychloroquine) administered at an adequate dose and duration
— Aetna, Wellmark BCBS policy ↗
Prior authorization
Precertification of a tocilizumab product is required of all Aetna participating providers and members in applicable plan designs.
— Aetna policy ↗When a drug is being reviewed for coverage under a member's medical benefit plan or is otherwise subject to clinical review (including prior authorization)
— Anthem / Elevance policy ↗Effective April 01, 2022 Prior Approval is required for Tocilizumab (e.g., Actemra) and Biosimilars.
— Arkansas BCBS policy ↗Prior authorization is required to ensure the safe, clinically appropriate, and cost-effective use of Actemra and its biosimilars
— BCBS Federal Employee Program policy ↗HCPA Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
— HCSC (IL/TX/OK/NM/MT) policy ↗Coverage eligibility for the use of both intravenous and subcutaneous tocilizumab (Actemra)
— BCBS Louisiana policy ↗
Quantity and frequency limits
8 mg/kg* as frequently as every 4 weeks
— Anthem / Elevance policy ↗No more than 4 total doses of tocilizumab (Actemra)
— BCBS Louisiana policy ↗Doses exceeding 600 mg per infusion are not recommended
— BCBS Minnesota policy ↗Adult Rheumatoid Arthritis & Polyarticular Juvenile
— Capital BlueCross policy ↗Giant Cell Arteritis 600 BU (600 mg) 28
— Capital BlueCross policy ↗IV: 800 mg every 4 weeks
— Centene / Ambetter policy ↗
Dosing rules
Rheumatoid Arthritis - 4 mg/kg every four weeks followed by an increase to 8 mg/kg every 4 weeks based on clinical response. Doses exceeding 800 mg per infusion are not recommended
— Arkansas BCBS policy ↗Giant Cell Arteritis - 6 mg/kg every 4 weeks in combination with a tapering course of glucocorticoids
— Arkansas BCBS policy ↗Polyarticular Juvenile Idiopathic Arthritis - 10 mg/kg every four weeks in individuals less than 30 kg and 8 mg/kg every four weeks in individuals at or above 30 kg
— Arkansas BCBS policy ↗Systemic Juvenile Idiopathic Arthritis - 12 mg/kg every two weeks in individuals less than 30 kg and 8 mg/kg every two weeks in individuals at or above 30 kg
— Arkansas BCBS policy ↗Cytokine Release Syndrome - 12 mg/kg in individuals less than 30 kg and 8 mg/kg in individuals at or above 30 kg alone or in combination with corticosteroids
— Arkansas BCBS policy ↗4mg/kg every 4 weeks, may increase to 8mg/kg every 4 weeks
— BCBS Nebraska policy ↗
Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.
How to bill Actemra
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J3262. Matching codes, units and JZ/JW wastage →
Which policy governs Actemra
No drug-specific LCD or Article — see the note at the top of this page. Find your MAC → What an LCD, an Article and an NCD each govern →
If a claim for Actemra is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J3262, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Actemra covered by Medicare?
- Yes. Actemra (J3262) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point.
- What diagnoses are covered for Actemra (J3262)?
- Medicare publishes no drug-specific covered-diagnosis list for J3262. The 11 ICD-10 codes here are the FDA-approved indications; an off-label use needs approved-compendium support (DrugDex, NCCN) to be payable.
- Which Medicare policy covers Actemra?
- No drug-specific LCD or Billing & Coding Article exists for Actemra. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- Why was my Actemra claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J3262. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Actemra's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Actemra cost & patient owe →Source & verification
- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Actemra — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Actemra prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — searched for “Actemra”; no drug-specific NCD, LCD or Billing & Coding Article exists, which is why the FDA-indicated codes above are the working list
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-08-26; we re-verify against CMS quarterly).
- Code licensing
- ICD-10-CM codes are public domain (CMS/CDC). CPT® codes are AMA-copyrighted and are intentionally not listed here — see the administration-code reference for those.
- Not advice
- This is general billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.
- How we build this
- Compiled programmatically from the CMS Coverage API under a founder-led methodology maintained by Erin Rose (Founder), and reviewed against the source article with a practitioner-correction loop. See our methodology and editorial policy.
- Spotted an error?
- Email editorial@carecostestimate.com.