OpenPayer

Summary of Changes in This Revision

This revision of Cigna's infliximab coverage guidance clarifies that prior authorization is required for benefit coverage of all infliximab products and that approvals are recommended only for those meeting the policy's specific Criteria and Dosing for listed indications. The document explicitly states that extended approvals are allowed when the patient continues to meet the stated criteria. It also reiterates that requests for doses outside the established dosing will be reviewed on a case-by-case basis by a clinician (Medical Director or Pharmacist).

Additionally, the revision reinforces administrative details about approval durations (defining 1 month as 30 days), and a requirement that initial prescribing be by or in consultation with a physician who specializes in the treated condition because of the specialized evaluation and monitoring needs for infliximab therapy. The revision also highlights interaction with a separate preferred-product management policy for inflammatory conditions.

Scope of Coverage and Prior Authorization Requirement

The policy statement makes clear that Prior Authorization is required for benefit coverage of all infliximab products covered by Cigna Companies. Coverage is contingent on meeting the policy's Criteria and Dosing for listed indications; approvals are recommended where those criteria are satisfied. Where dosage requests fall outside the established dosing documented in the policy, decisions are deferred to clinical review on a case-by-case basis by a Medical Director or Pharmacist.

The policy also notes that certain Cigna entities provide utilization review only and do not make coverage determinations, and that the member’s specific benefit plan document supersedes the Coverage Policy when conflicts exist. It emphasizes that benefits are ultimately determined by the applicable benefit plan in effect on the date of service, applicable laws/regulations, collateral materials including this Coverage Policy, and specific facts of the situation.

Dosing, Approval Duration, and Prescriber Requirements

Approvals are provided for specific durations as noted in the policy, with the policy defining 1 month equal to 30 days for authorization calculations. The policy permits extended approvals if the patient continues to meet the stated Criteria and Dosing for the indication. When dosing requests deviate from the documented dosing regimens, those requests will be evaluated individually by a clinician.

The policy requires that initial approval requires infliximab products to be prescribed by or in consultation with a physician who specializes in the condition being treated, citing the specialized skills needed for evaluation, diagnosis, monitoring of adverse events, and long-term efficacy assessment for infliximab therapy.

Interaction with Preferred Product Management and Administrative Limitations

This policy explicitly notes a separate management layer: use of preferred infliximab products is required before approval of a requested non-preferred infliximab intravenous product. The policy directs readers to the Inflammatory Conditions - Infliximab Intravenous Products Preferred Specialty Management Policy (PSM005) for additional preferred product criteria and exceptions. Thus coverage determinations for a non-preferred infliximab product depend both on the clinical criteria within this policy and adherence to the preferred-product policy where applicable.

Administratively, the document reiterates that Coverage Policies are guidance for interpreting standard benefit plans and are not treatment recommendations. It emphasizes that claims submitted without covered diagnosis/procedure codes consistent with the Coverage Policy will be denied, and that benefit plan documents or specific exclusions in a customer's plan take precedence over the Coverage Policy where conflicts exist.