Find policies, billing codes, payers, states, and providers
Remicade (infliximab) precertification request form and clinical intake
Customize your policy alerts
Sign up for all Aetna policy alerts
Know when Aetna releases new policies or updates existing guidance.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
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:
Form requests loading and maintenance dosing (weeks 0,2,6 and maintenance frequency).
Form solicits dosing support and prior treatment history.
Form requests induction (weeks 0,2,6) and maintenance dosing.
Form includes dosing support checkbox and prior therapy fields.
Form asks about corticosteroid trial/intolerance and disease severity.
Plaque psoriasis
Covered when ALL of the following are met:
Form includes BSA, special body areas, and reasons to avoid conventional agents.
Psoriatic arthritis (with/without plaque psoriasis)
Covered when ALL of the following are met:
Form asks about disease severity, enthesitis/axial disease, Simponi Aria history and biosimilar failure.
Pyoderma gangrenosum
Covered when ALL of the following are met:
Form requires specifying prior biologic use and responses.
Reactive arthritis
Covered when ALL of the following are met:
Form lists example contraindications and requests dosing support.
Rheumatoid arthritis
Covered when ALL of the following are met:
Form includes fields to justify non-standard dosing and documents prior therapy history.
Sarcoidosis
Covered when ALL of the following are met:
Form includes checkboxes for prior response/intolerance/contraindication.
Takayasu's arteritis
Covered when ALL of the following are met:
Form asks if disease is refractory and documents prior therapy responses.
Ulcerative colitis
Covered when ALL of the following are met:
Form explicitly requests loading and maintenance dosing and prior therapy status (Entyvio) and queries dose >10 mg/kg.
General and Continuation Authorization Criteria
Covered when ALL of the following are met
Reflected across form sections and required on continuation requests (maintenance dose/frequency, sample/PAP status).
Pediatric dosing acknowledgment
Covered when ALL of the following are met
Explicit checkbox present on form for prescriber acknowledgment.
Failure/intolerance to alternatives
Covered when ONE of the following is met as applicable to indication
Biosimilar failure must be due to a documented intolerable adverse event and form queries whether the adverse event was unexpected and not attributed to the active ingredient.
Assessment of clinical response for continuation
Covered when ALL of the following are met for continuation requests
Form lists specific response items per indication and requires documentation for continuation review.
Condition-specific medical necessity checklist
Covered when ALL of the following are met for the specific condition listed on the form
Applies across condition-specific checklists on the form.
From plaque psoriasis/PsA checklist.
Checklist allows 'none of the above' option; positive response expected for continuation.
Form marks which improvements apply for UC continuation review.
Dosing questions included to justify non-standard dosing.
Explicit acknowledgement fields on form for higher doses.
The precertification form explicitly asks whether the requested drug will be used in combination with any other biologic or targeted synthetic agent (examples listed). This combination-use field is captured on the form for review and must be completed as part of the required clinical information for all requests.
The form does not state explicit blanket exclusions on the listed disease pages. Instead, coverage evaluation relies on documented clinical details: confirmation of diagnosis, prescriber specialty or consultation, and documentation of prior therapies, intolerances, or contraindications for the specific indication (for example, prior conventional systemic therapy for plaque psoriasis or corticosteroid/immunosuppressive trials for sarcoidosis and Takayasu's). Providers must complete these fields for review.
The form specifically queries whether the prescribed dose exceeds 10 mg per kg. Requests that exceed this 10 mg/kg threshold are identified on the intake form and may require additional justification or review.
Sections that document improvement and specialist involvement solicit whether the drug is prescribed by or in consultation with the appropriate specialist and whether the patient has achieved or maintained a positive clinical response. These sections collect objective and subjective improvement items by condition (e.g., BSA for psoriasis, swollen/tender joint counts for RA, stool frequency/rectal bleeding for UC) but do not list explicit exclusions in these improvement or specialist fields.
The clinical information pages capture adverse events and medical instability that may affect the safe site of infusion. The form asks if the infusion is requested in an outpatient hospital setting, documents prior infusion-related or severe adverse events, presence of antibodies to infliximab, severe venous access issues, significant behavioral/cognitive impairments, and whether the patient is medically unstable (cardiopulmonary, respiratory, renal or other). These items are used to identify patients who may require outpatient hospital infusion or inpatient-level resources.
Requests that lack required evidence on the form — such as documentation of prior adequate trials or intolerances, specialty prescribing/consultation, dosing support from compendia or current literature, or rationale for non-standard dosing — may be considered incomplete and could be denied or delayed pending additional information. The form specifically asks for these items across multiple indications.
Use of Remicade without documentation of prior appropriate therapy trials or required specialist consultation is discouraged and may place the request at risk for denial. For example, the UC and certain dermatology/uveitis sections require documentation of prior alternatives or biosimilar failure where applicable; absence of that documentation may result in denial.
The form requires all fields to be completed and legible and includes an acknowledgement statement that knowingly providing materially false information is a fraudulent act. Requests with incomplete, illegible, or falsified information may be denied and the plan may request additional information to evaluate the request.
Coding, Dosing Thresholds, and Related Notes
| Administration code(s) (CPT) | Place on form where administration CPT codes are requested |
| Primary ICD Code | Field for patient's primary diagnosis ICD-10 code |
| Secondary ICD Code | Field for secondary ICD-10 code |
| Other ICD Code | Field for additional ICD-10 codes |
Provider Actions, Submission and Documentation Requirements
Precertification required — complete intake
Precertification intake is required for all initiation and continuation requests. Use Aetna's Remicade precertification form and complete all clinical indication–specific questions (diagnosis, specialist involvement, dosing, prior therapies, TB testing and results, and supporting clinical data) to avoid delays.
- Precertification phone: 1-866-752-7021 (TTY: 711)
- Fax: 1-888-267-3277
- Medicare Advantage Part B: use the Medicare request form
Form submission — use Aetna Remicade form
Submit precertification via Aetna’s Remicade form (phone or fax). All required administrative and clinical fields on the form must be completed and legible. For Medicare Advantage Part B requests, submit using the Medicare request form.
- Phone: 1-866-752-7021 (TTY: 711)
- Fax: 1-888-267-3277
Dosing documentation — support requested quantity
Indicate and document dosing rationale. Requests may be denied if the requested quantity or dose is not supported by the manufacturer prescribing information, compendia, or current literature. For pediatric patients and dose-escalation requests, document monitoring plans and rationale when doses exceed standard pediatric or adult limits.
- Document loading and maintenance doses (weeks 0,2,6 and maintenance frequency)
- If dose >5 mg/kg in pediatric patients or >10 mg/kg overall, provide justification and monitoring plan
- State whether dosing is supported by prescribing information or compendia and attach supporting literature when applicable
Specialist consultation — document prescriber/consultant
Document specialist involvement for the requested indication. Many indications require the drug be prescribed by or in consultation with a relevant specialist (e.g., dermatology, rheumatology, gastroenterology, ophthalmology, pulmonology, oncology). Lack of documentation of specialist prescribing or consultation may result in denial or delay.
- Specify prescriber specialty and provide consult notes when applicable
- Specialties called out include: Dermatologist, Gastroenterologist, Rheumatologist, Ophthalmologist, Pulmonologist, Oncologist/Hematologist
Entyvio failure required for UC when indicated
For ulcerative colitis (UC) requests, document prior ineffective response, intolerance, or contraindication to vedolizumab (Entyvio) when applicable. Failure to show Entyvio trial where required may lead to denial.
- Indicate whether Entyvio (vedolizumab) was tried and outcome (ineffective response, intolerance, contraindication)
Prior corticosteroid / immunosuppressive trial — document trials or contraindications
For indications that require it, document trials of corticosteroids or immunosuppressive therapy (e.g., azathioprine, methotrexate, cyclosporine, mycophenolate mofetil) including duration, response, intolerance, or contraindication. Provide reasons if corticosteroids or immunosuppressives were not used or not tolerated.
- State inadequate response or intolerance to corticosteroids/immunosuppressives where required
- For some indications (e.g., pyoderma gangrenosum, sarcoidosis, Takayasu's arteritis), document trials and outcomes
Form completeness and truthful submission — required
Complete the entire form truthfully and legibly. Incomplete, missing, or falsified submissions may prompt requests for additional information, delays, or denial and can constitute fraud with legal penalties.
- Signature and date required on the acknowledgement section
- The plan may request additional information or clarification as needed
Required submission elements — administrative fields
Provide required submission elements: patient demographics, insurance information, prescriber and dispensing provider details (including NPI, license), product name, dose, frequency, diagnosis (ICD codes), and TB screening status/results. Ensure contact information and office contact are included.
- Patient name, DOB, weight, height, allergies
- Prescriber NPI, state license, specialty, phone, fax, office contact
Required clinical details — diagnosis, prior therapies, supporting data
Include all required clinical details: primary diagnosis, relevant secondary diagnoses, prior treatments/trials (conventional therapies, biologics, biosimilars), reasons for selecting Remicade, and supporting clinical data (labs, imaging, endoscopy, disease activity scores). For continuation requests, document current maintenance dose, frequency, clinical response, and whether prior doses were received via samples or patient assistance programs.
- List prior biologics tried and outcomes (e.g., Avsola, Inflectra, Entyvio)
- Attach objective measures of response: CRP, fecal calprotectin, endoscopy, joint counts, BSA, disease activity scores
Continuation documentation — maintenance dose and response
For continuation requests, document maintenance dose and frequency, evidence of clinical benefit or stability (e.g., symptom improvement, objective markers), and whether therapy was received through samples or a manufacturer's patient assistance program. Indicate if supporting information is attached.
- Indicate maintenance dose/frequency and evidence of continued response
- Note if previous therapy was via samples or patient assistance program
Prior therapy / step requirements — document prior trials and outcomes
The form captures prior therapy and step-therapy requirements across indications. Answer all questions about inadequate response, intolerance, or contraindication to conventional therapies, prior biologics, and alternatives; provide documentation (e.g., dates, doses, reasons for discontinuation).
- Document specific prior conventional therapies tried (e.g., NSAIDs, methotrexate, sulfasalazine) and outcomes
- Document prior biologic/biosimilar use and reason for discontinuation (ineffectiveness, intolerance, adverse event)
Prior therapy requirements — document inadequate responses or contraindications
Providers must document prior inadequate response/intolerance/contraindication to conventional therapies or alternative biologics when required by the indication (step therapy). For some conditions, failure of specific agents (e.g., Entyvio for UC; Ilumya for psoriasis) is required before approval. Also document prior biosimilar failures and whether adverse events were unexpected and not attributable to the active ingredient.
- When biosimilar (Avsola, Inflectra) failures are cited, indicate whether the adverse event was unexpected and not attributable to the active ingredient
- For plaque psoriasis and related indications, document attempts at phototherapy or systemic agents when BSA <10%
Step therapy / alternatives — document trials or justify exceptions
When alternative biologics or therapies are part of the step pathway, provide documentation of trial and outcome (ineffective response, intolerance, or contraindication). Examples include vedolizumab for UC, Ilumya for psoriasis, and other indication-specific alternatives. Lack of documented trials may result in denial.
- Indicate trials of alternative biologics and outcomes where applicable
- Provide clinical rationale when skipping step therapies (e.g., contraindication, intolerance)
Missing clinical documentation — risk of denial or delay
If required clinical documentation is missing (diagnoses, specialist consult, prior therapy trials, TB testing, dosing justification), the request may be delayed or denied. Provide clear, legible, and complete responses to each indication-specific checklist item.
- Failure to provide required documentation may result in denial or request for additional information
Background and Clinical Context
Background: Remicade (infliximab) is an intravenous anti‑TNF biologic used for multiple immune‑mediated disorders. The precertification form captures disease‑specific dosing (loading and maintenance), prior biologic or targeted therapy exposure (including biosimilars), TB screening status, and reasons for higher dosing or use in special populations such as pediatric patients.
Definitions and Testing Requirements
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.