Authorization of 12 months may be granted when the indication-specific criteria below are met.
Gastrointestinal indications: Covered for Crohn's disease (adult and pediatric ≥6) and ulcerative colitis (≥6) with inadequate response to conventional therapyclinical judgment
Includes fistulizing Crohn's disease; Zymfentra limited to adults and maintenance following IV infliximab as specified in product section
Rheumatologic/dermatologic indications: Covered for rheumatoid arthritis (in combination with methotrexate or leflunomide unless contraindicated), ankylosing spondylitis/non-radiographic axial spondyloarthritis, psoriatic arthritis, chronic severe plaque psoriasis, hidradenitis suppurativa, juvenile idiopathic arthritis, pyoderma gangrenosum, sarcoidosis, Takayasu's arteritis, uveitis, reactive arthritis, and immune checkpoint inhibitor–related toxicity or acute graft versus host disease when indication-specific prior therapy criteria are met.indication-specific prior therapy failure or intolerance as specified below
Applies to Avsola, Inflectra, infliximab (Remicade) and Renflexis; see individual sections for required prior trials and exceptions
Rheumatoid arthritis — prior biologic pathway (Path A): Authorization may be granted when member previously received a biologic or targeted synthetic drug indicated for RA and the requested medication is prescribed in combination with methotrexate or leflunomide unless there is a documented clinical reason not to use those agents.prior biologic use
See biomarker pathway and Appendix A for reasons not to use methotrexate/leflunomide
Rheumatoid arthritis — biomarker pathway: Authorization may be granted when member has positive RF or anti-CCP OR has had testing for RF, anti-CCP and CRP/ESR, AND the requested medication is prescribed with methotrexate or leflunomide or there is a clinical reason not to use those agents, AND the member has had an inadequate response to at least a 3-month trial of methotrexate at adequate dosing (titrated to ≥15 mg/week) or has intolerance/contraindication.positive biomarker(s) and methotrexate trial/intolerance
Laboratory documentation required for initial requests
AS/nr-axSpA initial criteria: Authorization may be granted when member previously received a biologic/targeted synthetic for AS/nr-axSpA OR member has had an inadequate response to at least two NSAIDs OR has intolerance/contraindication to two or more NSAIDs.two NSAID trial failure/intolerance
Applies to Avsola, Inflectra, infliximab, Remicade, Renflexis only
Psoriatic arthritis initial criteria: Authorization may be granted when member previously received a biologic/targeted synthetic for PsA OR when member with mild–moderate disease had inadequate response to methotrexate, leflunomide, or another conventional synthetic DMARD at adequate dose/duration, or has intolerance/contraindication to those agents, or member has enthesitis or predominantly axial disease; severe disease also qualifies.prior therapy failure or severe disease
Applies to listed infliximab products
Plaque psoriasis initial criteria: Authorization may be granted for moderate to severe plaque psoriasis when any of the following are met: involvement of crucial body areas; ≥10% body surface area (BSA) affected; or ≥3% BSA with inadequate response/intolerance to phototherapy or methotrexate/cyclosporine/acitretin or clinical reason to avoid those agents.BSA thresholds as specified
Applies to listed infliximab products
Behçet's disease initial criteria: Authorization may be granted when member previously received Otezla or a biologic for Behçet's disease OR member had inadequate response to at least one non-biologic medication (e.g., azathioprine, colchicine, cyclosporine, systemic corticosteroids).one non-biologic trial or prior biologic
Applies to listed infliximab products
Hidradenitis suppurativa initial criteria: Authorization may be granted when member previously received a biologic indicated for severe, refractory hidradenitis suppurativa OR member had inadequate response to an oral antibiotic regimen used for HS for at least 90 days or has intolerance/contraindication to oral antibiotics.90-day antibiotic trial or prior biologic
Applies to listed infliximab products
Juvenile idiopathic arthritis initial criteria: Authorization may be granted when member previously received a biologic or targeted synthetic for JIA OR when member had inadequate response to methotrexate or another conventional synthetic DMARD at adequate dose/duration, OR inadequate response to scheduled NSAIDs and/or intra-articular glucocorticoids plus at least one risk factor for poor outcome (e.g., ankle/wrist/hip/SI/TMJ involvement; erosive disease; enthesitis; delayed diagnosis; elevated inflammation markers; symmetric disease).as specified
Applies to listed infliximab products
Pyoderma gangrenosum initial criteria: Authorization may be granted when member previously received a biologic indicated for pyoderma gangrenosum OR member had inadequate response to corticosteroids or immunosuppressive therapy (e.g., cyclosporine, mycophenolate mofetil) or has intolerance/contraindication to those therapies.as specified
Applies to listed infliximab products
Sarcoidosis initial criteria: Authorization may be granted when member had inadequate response to corticosteroids or immunosuppressive therapy OR has intolerance/contraindication to those therapies.as specified
Applies to listed infliximab products
Takayasu's arteritis initial criteria: Authorization may be granted when member had inadequate response to corticosteroids or immunosuppressive therapy (e.g., methotrexate, azathioprine, mycophenolate mofetil) OR has intolerance/contraindication to those therapies.as specified
Applies to listed infliximab products
Uveitis initial criteria: Authorization may be granted when member previously received a biologic indicated for uveitis OR member had inadequate response to corticosteroids or immunosuppressive therapy (e.g., methotrexate, azathioprine, mycophenolate mofetil) or has intolerance/contraindication to those therapies.as specified
Applies to listed infliximab products
Reactive arthritis initial criteria: Authorization may be granted when member previously received a biologic indicated for reactive arthritis OR member had inadequate response to at least a 3-month trial of sulfasalazine (titrated to 1000 mg twice daily) or methotrexate (titrated to ≥15 mg/week), or has intolerance/contraindication to those agents.3-month trial or intolerance
Applies to listed infliximab products
Immune checkpoint inhibitor-related toxicity initial criteria: Authorization durations depend on severity: 6 months may be granted for inadequate response/intolerance/contraindication to corticosteroids; 12 months may be granted for moderate/severe inflammatory arthritis with inadequate response/intolerance/contraindication to corticosteroids.severity-based
Applies to listed infliximab products
Acute graft versus host disease initial criteria: Authorization may be granted when member has inadequate response to systemic corticosteroids or has intolerance/contraindication to corticosteroids.as specified
Applies to listed infliximab products
Other indications: Authorization of 12 months may be granted for other indications outlined in initial criteria when members achieve or maintain positive clinical response per the continuation section.not specified
Applies to Avsola, Inflectra, infliximab, Remicade, Renflexis only
Pre-initiation safety requirement: For all indications, member must have documented negative tuberculosis test (TST or IGRA) within 12 months prior to initiating therapy if biologic‑naïve; positive tests require evaluation to exclude active TB and treatment of latent TB before initiation.within 12 months
Do not administer medication to members with active TB; cannot be used concomitantly with another biologic/targeted synthetic for same indication