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Infliximab Intravenous Products Preferred Specialty Management Policy
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Cigna's preferred specialty management program that governs prior authorization and preferred product sequencing for infliximab intravenous products for members covered by Cigna-administered health benefit plans.
No material clinical or coverage changes in this revision.
Coverage Criteria for Infliximab Intravenous Products
Preferred Specialty Management and Non-Preferred Product Exception
Infliximab intravenous non-preferred products are considered medically necessary when the following non‑preferred product exception criteria are met. Any other exception is considered not medically necessary.
Overall exception approval
- A: Patient meets the standard Inflammatory Conditions - Infliximab Intravenous Products Prior Authorization Policy criteria
See read-with prior authorization policy
B
- i: Patient has tried ONE of Inflectra or Avsola
Step therapy: try a Preferred Product prior to Non-Preferred
- ii: Patient cannot continue to use the Preferred medication due to a formulation difference in the inactive ingredient(s) (e.g., differences in stabilizing agent, buffering agent, and/or surfactant) which, according to the prescriber, would result in an inability to tolerate or safely receive the Preferred product
Prescriber must document the specific inactive ingredient formulation difference and clinical rationale why the Preferred product cannot be used
Requests for non-preferred infliximab products that do not meet the exception criteria are considered not medically necessary.
Infliximab intravenous non-preferred products are considered medically necessary only when the non-preferred product exception criteria are fully met. Per the policy, all patients (for Preferred and Non-Preferred products) must meet the standard Inflammatory Conditions - Infliximab Intravenous Products Prior Authorization Policy criteria, and patient must have tried at least one Preferred Product (Avsola or Inflectra) prior to approval of a Non-Preferred Product. Requests that do not meet the exception criteria are not medically necessary.
Requests for Non-Preferred infliximab products that do not satisfy the listed non-preferred product exception criteria are considered not medically necessary. Providers must document that the patient meets the required prior authorization criteria and the exception criteria (including preferred product trial and prescriber justification related to formulation/inactive ingredient differences) for consideration of a Non-Preferred product approval.
Coding and Billing Codes
| not specified | Document does not list specific CPT/HCPCS/ICD-10 codes; providers must use the most appropriate codes as of the service date. |
Provider Actions, Authorization & Billing Requirements
Prior authorization required
All infliximab intravenous products (Preferred and Non‑Preferred) require meeting the standard Inflammatory Conditions - Infliximab Intravenous Products Prior Authorization Policy criteria; approvals follow the duration specified in that prior authorization policy.
Step: try a Preferred infliximab product first
Before a Non‑Preferred infliximab product will be approved, the patient must have tried at least one Preferred Product (Avsola or Inflectra); Non‑Preferred requests are reviewed using the exception criteria.
- Preferred Products: Avsola, Inflectra
- Non‑Preferred requests evaluated against the Non‑Preferred Product Exception Criteria
Use appropriate covered codes when billing
When billing, providers must use the most appropriate codes as of the effective date of the submission; reimbursement is not allowed when billed for conditions or diagnoses not covered under this Coverage Policy.
- Use covered diagnosis and/or procedure code(s) under the applicable Coverage Policy.
- Claims lacking covered codes will be denied as not covered.
Denial risk for missing covered codes
Claims submitted for services that are not accompanied by covered diagnosis and/or procedure codes under the applicable Coverage Policy will be denied as not covered.
Background
Infliximab intravenous products (including brand Remicade and biosimilars such as Avsola, Inflectra, and Renflexis) are indicated for inflammatory conditions and share the same mechanism of action, route, dosage form, and strength. Biosimilars listed have demonstrated biosimilarity to Remicade but have not been designated as interchangeable; an authorized generic is produced using the same cell line as brand Remicade.
Under this Preferred Specialty Management program, members are directed to try at least one Preferred Product (Avsola or Inflectra) before a Non-Preferred infliximab product will be approved, and Non-Preferred products may be approved only when the specified non-preferred product exception criteria are met.
Definitions
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