Infliximab (for Ohio Only)
Defines medical benefit drug policy for infliximab products for members in Ohio and how medical necessity is determined under Ohio Administrative Code and the Ohio Department of Medicaid criteria.
Removed reference link to the Medical Benefit Drug Policy titled Maximum Dosage and Frequency (for Ohio Only) and archived previous policy version CSOH2025D0004.B.
Coverage Criteria for Infliximab Products (Ohio)
Coverage when Ohio Medicaid criteria met
Covered when medical necessity criteria from the Ohio Department of Medicaid Unified Preferred Drug List are met.
Refer to Ohio Medicaid criteria for specific diagnoses, prior authorization, and quantity limits
This policy applies only to the state of Ohio. Requests for services originating outside of Ohio are not governed by this document and should be evaluated under the applicable state or payer-specific policies for that jurisdiction. Refer to Ohio-specific guidance when determining applicability and coverage.
Use of infliximab products that does not meet the Ohio Department of Medicaid Unified Preferred Drug List Criteria or is otherwise stated as unproven will be evaluated for medical necessity under Ohio Administrative Code 5160-1-01 and may be deemed not medically necessary. Coverage or quantity requests that exceed Ohio criteria are subject to denial.
Initial Therapy and Determination Rules
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