CurrentAetnaPolicy N/A

Remicade (infliximab) precertification request form and clinical intake

This document is Aetna's precertification request form and clinical intake for Remicade (infliximab) injectable therapy. It governs the information providers must submit to request authorization for initiation or continuation of infliximab for Aetna members.

Policy Summary

PayerAetna

PolicyRemicade (infliximab) precertification request form and clinical intake

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification must be requested using this form for initiation or continuation of Remicade and all required clinical fields must be completed and legible.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10pages

multipleindications

requiredclinical documentation

requiredspecialist consult

1-8dosing thresholds

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Coverage Criteria and Indication-specific Requirements

Indication-specific intake criteria

For each listed indication the form requires confirmation of diagnosis, prescriber specialty or consultation, prior therapy trials or contraindications, and support for requested dosing:

Ankylosing spondylitis / nr-axSpA: Requires indication selection (AS or nr-axSpA); confirmation that the drug is prescribed by or in consultation with a rheumatologist; documentation of prior biologic or targeted synthetic use; inadequate response to at least two NSAIDs or intolerance/contraindication to at least two NSAIDs; documentation regarding Simponi Aria; and whether biosimilars Avsola or Inflectra were tried and failed due to a documented intolerable adverse event (and whether the adverse event was unexpected and not attributed to the active ingredient).NA

Form requests loading and maintenance dosing (weeks 0,2,6 and maintenance frequency).

Behçet's disease: Requires statement that requested quantity is supported by dosing guidelines/compendia; confirmation that the drug is prescribed by or in consultation with a rheumatologist; documentation of prior nonbiologic therapy failure (e.g., apremilast, colchicine, systemic glucocorticoids, azathioprine) or other relevant therapy; and prior biologic or Otezla exposure documented.NA

Form solicits dosing support and prior treatment history.

Crohn's disease: Requires documentation of moderately to severely active Crohn's disease; confirmation that the drug is prescribed by or in consultation with a gastroenterologist; patient age captured (pediatric vs adult); documentation of ineffective response, contraindication, or intolerance to Entyvio when applicable; and whether biosimilars Avsola or Inflectra were tried and failed due to a documented intolerable adverse event. For pediatric patients the prescriber must acknowledge monitoring if dose above 5 mg/kg and indicate if prescribed dose exceeds induction/maintenance 10 mg/kg limits.NA

Form requests induction (weeks 0,2,6) and maintenance dosing.

Hidradenitis suppurativa: Requires that requested quantity is supported by dosing guidelines; confirmation of severe, refractory disease; that the drug is prescribed by or in consultation with a dermatologist or rheumatologist; documentation of prior biologic exposure; and inadequate response or intolerance/contraindication to at least 90 days of oral antibiotics. Documents whether Avsola or Inflectra were tried and failed due to an intolerable adverse event.NA

Form includes dosing support checkbox and prior therapy fields.

Immune checkpoint inhibitor toxicity (including immunotherapy arthritis): Requires that requested quantity is supported by dosing guidelines; confirmation that the drug is prescribed by or in consultation with an oncologist/hematologist when applicable; documentation of inadequate response, intolerance, or contraindication to corticosteroids; and assessment of disease severity (e.g., moderate/severe diarrhea or colitis, severe disease for immunotherapy arthritis).NA

Form asks about corticosteroid trial/intolerance and disease severity.

Plaque psoriasis