CurrentCareSourcePolicy N/A

PHARMACY POLICY STATEMENT Arkansas PASSE

Defines medical-benefit coverage criteria, prior authorization, dosing, quantity limits, allowed sites of service, and not medically necessary indications for Inflectra (infliximab-dyyb) for Arkansas PASSE members under CareSource.

Policy Summary

PayerCareSource

PolicyPHARMACY POLICY STATEMENT Arkansas PASSE

Policy CodePolicy N/A

Change TypeNew policy (created 10/03/2019)effective 01/01/2022

Effective DateJan 1, 2022

Next Review Date

Key ActionPrior authorization is required for Inflectra as a non-preferred medical benefit product; approval contingent on meeting the indication-specific clinical criteria and prior therapy requirements.

SourceLink

POLICY UPDATE CHANGES

New policy for Inflectra created on 10/03/2019.

6Covered Indications (major categories listed)

45Not medically necessary indications listed

1200 mgQuantity limit per dose

Coverage Summary

Inflectra (infliximab-dyyb) is designated a non-preferred infliximab biosimilar and is covered only under the medical benefit with prior authorization required. Coverage is contingent on specialist prescribing (rheumatologist, gastroenterologist, or dermatologist as specified per indication), documented negative TB test (PPD or IGRA) within 12 months prior to initiation, and documented trial and treatment failures or contraindications to preferred biologics (Enbrel and Humira) as specified by indication. Dosing and quantity limits apply per policy (e.g., 5 mg/kg at weeks 0, 2, and 6 then every 8 weeks for most indications; 3 mg/kg schedule for RA; quantity limit 1200 mg (120 units) per dose); higher doses/frequencies require medical necessity justification. Allowed sites of service include office/non-hospital outpatient facility. This policy and scope apply to Arkansas PASSE CareSource members.

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Initial Therapy Criteria (by indication)

General coverage prerequisites

Inflectra is non-preferred and covered under the medical benefit only when ALL of the following are met:

ALL of the following

General coverage prerequisites
- Drug is prescribed for a clinically diagnosed covered disease state listed in this policy (e.g., AS, CD, PsO, PsA, RA, UC).
- Prior authorization is obtained (Prior Authorization Required - Non-Preferred Product).
- Medication is prescribed by a specified specialist according to the indication (rheumatologist, gastroenterologist, or dermatologist as specified per disease state).
- Member has a documented negative TB test (PPD or IGRA) within 12 months prior to starting therapy.
- Member has documented trial and treatment failures or contraindications to preferred products (Enbrel and Humira) as specified per indication.
- Dosing and quantity limits must be within policy-allowed dosages; any higher doses or frequencies require medical necessity documentation.
  Quantity limit 1200 mg (120 units) per dose as stated in policy.

Ankylosing Spondylitis (AS) - Initial authorization