CurrentHighmark Blueshield NenyPolicy N/A

Outpatient infliximab (medical injectable) authorization request form

Form and authorization requirements for outpatient medical administration of infliximab and biosimilars; used by providers to request prior authorization from Highmark BlueShield (Medical Benefit only) for commercial and Medicare members.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient infliximab (medical injectable) authorization request form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Outpatient Medical Injectable Infliximab Authorization Request Form (fax to 833-619-5745) with required clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5listed administration site options

4preferred products enumerated

8diagnosis options listed

1fax number for submission

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization and product preference criteria

Coverage for infliximab or biosimilar outpatient infusion is subject to product preference and required clinical documentation. Requests must be submitted on the Outpatient Medical Injectable Infliximab Authorization Request Form and include the items below.

Primary requirements: Provider must submit the completed authorization form including member and physician information, site of care, drug name/dose/quantity, diagnosis (ICD-10), member weight, and attach pertinent clinical documentation.

Form must be faxed to 833-619-5745 per submission instructions.

Required clinical attachments: Attach clinical information documenting diagnosis, disease severity (moderate to severe where applicable), list of prior therapies tried and failed, date of last infusion for continuation requests, and evidence of disease stability or beneficial response when requesting continuation of therapy.

Include whether infliximab is used with methotrexate and explanation if not.

Product selection logic: Preferred products (Remicade J1745, Renflexis Q5104, Avsola Q5121) should be used for all indications. A non-preferred product (Inflectra Q5103) will be considered only after documented failure, intolerance, or contraindication to BOTH preferred products.

Medicare members already established on non-preferred therapy are exempt from the try/prefer requirement.

Non-preferred infliximab products are excluded from routine consideration. A non-preferred product will be considered only when the member has documented therapy failure after an adequate therapeutic trial, intolerance, or a contraindication to BOTH preferred products. Medicare members currently established on non-preferred therapy are exempt from the requirement to try preferred products.

Providers must submit the completed Outpatient Medical Injectable Infliximab Authorization Request Form with supporting clinical documentation to justify use of a non-preferred product, including clear evidence of the required failures, intolerances, or contraindications to the preferred agents.

Provider Actions and Requirements

Prior Authorization

Form submission and affected HCPCS codes

Prior authorization request must be submitted using the Outpatient Medical Injectable Infliximab Authorization Request Form and faxed to 833-619-5745 (Medical Benefit only). Include member identifiers and benefit type (Medicare or Commercial).

Form: Outpatient Medical Injectable Infliximab Authorization Request Form (include Member Name, DOB, Member UMI, address, benefit type)
Fax: 833-619-5745 (Medical Benefit only)
Affected HCPCS/HCPCS-like codes (product-specific): J1745 (Remicade), Q5104 (Renflexis), Q5121 (Avsola), Q5103 (Inflectra)

Denial Risk

Potential denial for non-preferred product without documented failure/intolerance

A non-preferred infliximab product may be denied if there is no documented failure, intolerance, or contraindication to BOTH preferred products (Remicade J1745 and Renflexis Q5104 / Avsola Q5121 as listed).

Preferred products: Remicade (J1745), Renflexis (Q5104), Avsola (Q5121)
Non-preferred example: Inflectra (Q5103) — approval requires documented failure/intolerance to BOTH preferred products or documented contraindication
Exception: Medicare members currently established on non-preferred therapy are not required to try preferred option

Documentation Required

Required supporting clinical documentation

Attach all pertinent clinical information to support the request, including diagnosis, member weight, list of prior therapies tried and failed, dates of prior infusions, and whether infliximab is used in combination with methotrexate. Verify member eligibility and benefits through the health plan.

Include diagnosis code (ICD-10) and diagnosis description
Document member weight and indication (e.g., RA, CD, UC, PsA, AS, Uveitis, JRA)
List all previous therapies tried and reason for failure or intolerance
State whether infliximab is combined with methotrexate; if no, provide explanation
Attach proof of prior infusion dates and response/stability (new start vs continuation)

Background

Infliximab and its biosimilars are intravenous tumor necrosis factor-alpha (TNF-α) inhibitors used to treat multiple inflammatory conditions. Authorization requests require documentation of the member's diagnosis, weight, and pertinent clinical information such as prior therapies tried and failed, date of last infusion, and evidence of disease stability or response when requesting continuation.

For coverage determination purposes this policy distinguishes between preferred infliximab products — Remicade (J1745), Renflexis (Q5104), and Avsola (Q5121) — and the listed non-preferred biosimilar Inflectra (Q5103). Preferred products should be used for all indications unless the member meets the exception criteria described in this policy.

Definitions

inv-09: Continuation of Therapy — definition / short descriptor

TermContinuation of Therapy

DefinitionMember is currently receiving infliximab (or biosimilar) and the request is to continue ongoing outpatient infusion therapy; include date of last infusion and evidence of disease stability or beneficial response.

Required documentationAttach clinical information showing prior response or stability, date of last infusion, current diagnosis, member weight, and list of prior therapies.

inv-10: New Start — definition / short descriptor

TermNew Start

DefinitionInitiation of infliximab (or biosimilar) therapy for a member not currently receiving the drug; documentation must list prior therapies tried/failed and confirm diagnosis and disease severity.

Required documentationProvide diagnosis code and description, member weight, list of previous therapies tried and failed, and whether infliximab will be used with methotrexate.