CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Medical Injectable Rituximab and Biosimilars Request Form — Coverage Criteria

This form governs prior authorization requests for outpatient medical benefit administration of rituximab and specified biosimilars for oncology, rheumatoid arthritis, and other non-oncology indications for Highmark Blue Shield members.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Medical Injectable Rituximab and Biosimilars Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Outpatient Medical Injectable Rituximab and Biosimilars Request Form via fax to 833-619-5745 with member, provider details, diagnosis code(s), and required clinical attachments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3preferred products for oncology

2preferred products for RA

2non-preferred products

833-619-5745fax to submit request

Noted

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.

Coverage Criteria

General coverage criteria

Covered when ALL of the following are met for the relevant indication

Submission requirements: Completed request form with member and provider information, diagnosis code(s), and attached pertinent clinical information (prior therapies, chemo regimen, CD20 status for oncology, dose/frequency, RA disease activity, date of last infusion where applicable)

See documentation field for specifics

Oncology product selection: Requested product is a preferred oncology product (Ruxience Q5119, Riabni Q5123, or Rituxan Hycela J9311) OR when non-preferred product is requested, there is documented failure or intolerance to BOTH preferred products unless Medicare member already established on non-preferred therapy

For Rituxan Hycela, patient must have received at least one full dose of a rituximab product by IV infusion

Rheumatoid arthritis product selection: Requested product is a preferred RA product (Ruxience Q5119 or Riabni Q5123); if non-preferred requested, documented failure/intolerance to both preferred agents required unless Medicare exception applies

Confirm RA is moderately to severely active for initiation; document continuation or new start and response to therapy

Clinical specifics for oncology: Provide cancer type and histology, disease stage, chemotherapy regimen, line of therapy, prior therapies and whether patient progressed or relapsed, and CD20 status

If CD20-negative, indicate 'No' or 'Not applicable' on the form

Clinical specifics for non-oncology: Provide prior medications for the condition, concurrent medications, and dose/frequency of rituximab therapy

Attach supporting documentation such as progress notes and prior infusion records

Requests for a non-preferred rituximab product (listed on the form as Rituxan J9312 or Truxima Q5115) must include documentation that the member has experienced a documented drug therapy failure after an adequate therapeutic trial of BOTH preferred products, or that both preferred products were not tolerated or are contraindicated. Medicare members currently established on a non-preferred therapy are exempt from the try‑preferred requirement. Ensure member eligibility and benefits are verified with the health plan.

Coding

Preferred HCPCS/ASP codes for oncologyHCPCS

Q5119	Ruxience
Q5123	Riabni
J9311	Rituxan Hycela

Preferred HCPCS/ASP codes for rheumatoid arthritisHCPCS

Q5119	Ruxience
Q5123	Riabni

Non-preferred HCPCS/ASP codesHCPCS

J9312	Rituxan
Q5115	Truxima

Provider Actions & Submission Requirements

Prior Authorization

Form submission requirement — Completed form and required identifiers

Submit the completed Outpatient Medical Injectable Rituximab and Biosimilars Request Form (Medical Benefit only) via fax to 833-619-5745. Include member identifiers (name, DOB, UMI), member eligibility (Medicare/commercial), requesting provider and facility details (provider name, NPI, address, office contact/phone/fax, facility and facility NPI), date of service, and diagnosis code(s).

Fax number: 833-619-5745
Include: Member Name, DOB, UMI, Medicare/Commercial indicator
Include: Requesting physician name, NPI, address, office contact phone and fax
Include: Facility name, facility NPI, facility address, date of service, diagnosis code(s)

Step Therapy

Preferred-then-nonpreferred sequencing — Document trials of preferred products first

Requests for non-preferred rituximab products will be reviewed only when there is documentation that the member has experienced drug therapy failure or intolerance to preferred products. The form must document whether the member failed or did not tolerate preferred agents (Ruxience and Riabni).

Background

Rituximab and its biosimilars are used interchangeably for CD20‑directed indications represented on the form. The form distinguishes preferred products (e.g., Ruxience Q5119, Riabni Q5123, Rituxan Hycela J9311) from non‑preferred products (Rituxan J9312, Truxima Q5115) and requires documentation of prior trials or intolerance to preferred agents when a non‑preferred product is requested. The form explicitly notes that a non‑preferred product will be considered only after an adequate therapeutic trial and documented failure of BOTH preferred products, except for Medicare members already established on the non‑preferred therapy.

Definitions & Assessment Fields

Whether the patient's disease expresses the CD20 antigen

Response options on formYes / No / Not applicable (checkboxes provided)

Context requiredAsked specifically for oncology indications to confirm CD20 expression status

Placement on formQuestion 5 under oncology section requests CD20 status

Provider assessment of rheumatoid arthritis activity

Assessment options on formYes / No / New Start / Continuation of Therapy (checkboxes provided)

Additional required infoDate of last infusion must be provided for continuation assessments

Follow-up question

Initial Therapy Criteria

Initial therapy rules

Product selection and sequencing for initiation

Preferred product initiation: Initiate therapy with a preferred product for the indication (Oncology preferred: Ruxience Q5119, Riabni Q5123, Rituxan Hycela J9311; RA preferred: Ruxience Q5119, Riabni Q5123)

Rituxan Hycela requires prior IV rituximab exposure (at least one full IV dose) per the Rituxan Hycela policy

Non-preferred initiation: Non-preferred products (e.g., Rituxan J9312, Truxima Q5115) may only be authorized after documented drug therapy failure or intolerance to BOTH preferred agents, or when both preferred agents are contraindicated or not tolerated

Medicare members already established on a non-preferred therapy are exempt from the requirement to try preferred products

Continuation Criteria

RA continuation criteria

For rheumatoid arthritis continuation

RA continuation: Indicate 'Continuation of Therapy' on the form, provide date of last infusion, and submit evidence of disease stability or beneficial response to therapy

Attach clinical documentation (disease activity assessment, progress notes, prior infusion records)

Step Therapy / Sequencing Table

Step	Requirement
1	Member must have documented drug therapy failure or intolerance after an adequate therapeutic trial of BOTH preferred products before a non‑preferred rituximab product will be considered.
Exception	Medicare members currently established on a non‑preferred rituximab therapy are exempt from the preferred‑first requirement and are not required to trial preferred products.

Site of Care

Note

Form is for outpatient medical benefit administration; include facility and date of service

This form is intended for outpatient medical benefit administration and includes fields to capture the facility, facility NPI, facility address, and date of service to support outpatient infusion billing.

Facility name, facility NPI, facility address and Date of Service fields are on the form
Form labeled: Outpatient Medical Injectable Rituximab and Biosimilars Request Form (Medical Benefit Only)

Rituximab Products & Preferences

Billing Rule

Preferred oncology products: Ruxience, Riabni, Rituxan Hycela (J9311)

Preferred products listed for oncology indications on the form are Ruxience (Q5119), Riabni (Q5123), and Rituxan Hycela (J9311); Rituxan Hycela requires the patient to have received at least one full IV dose of a rituximab product per the form note.

Ruxience — Q5119
Riabni — Q5123
Rituxan Hycela — J9311 (requires prior IV rituximab exposure)

Billing Rule

Preferred RA products: Ruxience and Riabni

Preferred products listed for rheumatoid arthritis on the form are Ruxience (Q5119) and Riabni (Q5123).

Ruxience — Q5119
Riabni — Q5123