CurrentHighmark DelawarePolicy N/A

Outpatient Medical Injectable Infliximab Authorization Request Form

Form and instructions used by providers to request authorization for outpatient medical injectable infliximab (medical benefit) for Highmark Delaware members. Affects prescribing clinicians, infusion providers, and billing staff requesting prior authorization for infliximab and biosimilars.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Medical Injectable Infliximab Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit the authorization request form with required clinical information via fax to 833-581-1861 to request outpatient medical benefit coverage for infliximab or listed biosimilars.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

833-581-1861authorization submission fax number

Preferred / Non-preferreddrug formulary distinction

4site of care options

multipleindication options

Coverage Criteria

Initial authorization criteria

Covered when ALL of the following are met

Form submission: Authorization request form submitted via fax to 833-581-1861 with required fields completed (member, provider, place of service, drug, dose, diagnosis).

See prior_auth module for codes

Clinical attachments: Pertinent clinical information attached including prior therapies tried and failed, date of last infusion, documentation of disease stability or beneficial response, diagnosis code, member weight, and explanation if not using methotrexate when indicated.

Supports medical necessity determination

Preferred product requirement: If requesting a non-preferred infliximab product (Remicade J1745 or Renflexis Q5104), there must be documented failure, intolerance, or contraindication to BOTH preferred products (Avsola Q5121 and Inflectra Q5103).

Medicare members currently established on a non-preferred therapy are not required to try a preferred option

For Medicare members who are already established on a non-preferred infliximab product, the policy does not require a trial of a preferred product. In other words, Medicare members currently established on a non-preferred therapy are not required to try a preferred option when requesting ongoing coverage for that therapy.

Requests that lack documentation of prior therapies when such information is required, or that are submitted without the pertinent clinical attachments (for example, prior therapy failures, disease severity, date of last infusion, diagnosis code, member weight, or explanation if not using methotrexate), may be deemed not medically necessary. Providers should ensure the form includes complete prior-therapy history and the other requested clinical details to avoid denial or processing delay.

Provider Actions and Submission Requirements

Prior Authorization

Authorization submission and codes

Providers must submit the Outpatient Medical Injectable Infliximab Authorization Request Form (medical benefit only) via fax to 833-581-1861. Include the completed drug information portion with drug name, strength/dose, dates of service, directions, quantity, ICD-10 diagnosis code and description, member weight, indication, whether infliximab is used with methotrexate, and list of all previous therapies tried and failed.

Fax: 833-581-1861
Include completed Drug Information fields: drug name, dose/strength, dates of service, directions, quantity, ICD-10 code, diagnosis description, member weight, indication selection, methotrexate co‑therapy status, date of last infusion
Attach documentation of previous therapies tried and failed

Step Therapy

Preferred-first requirement

Non-preferred infliximab products will be considered only when the member has a documented drug therapy failure after an adequate therapeutic trial, intolerance, or contraindication to BOTH preferred products. Note: Medicare members currently established on a non-preferred therapy are not required to try a preferred option.

Preferred products (for all indications): Avsola (Q5121), Inflectra (Q5103)
Non-preferred products: Remicade (J1745), Renflexis (Q5104)
Non-preferred use requires documented failure/intolerance to BOTH Avsola and Inflectra

Documentation Required

Required clinical attachments

Attach all pertinent clinical information with the authorization form. This includes date of last infusion, documentation that the member has demonstrated disease stability or a beneficial response (for continuation requests), and whether the request is a new start or continuation of therapy.

Attach: clinical notes, infusion records, labs, imaging as relevant
Indicate: New Start or Continuation of Therapy
Include date of last infusion and documentation of response or stability

Denial Risk

Documentation and prior therapy

Failure to document prior therapies tried and failed, or to verify member eligibility and benefits, may result in denial or processing delays. Ensure the form lists all previous therapies and answers the question about documented failure or intolerance to preferred products. Verify member eligibility and benefits through the health plan before submitting.

Incomplete documentation of prior therapy trials may lead to denial or delay
Confirm member eligibility/benefits prior to submission
Answer: Has the member experienced documented failure/intolerance to the preferred products? (Avsola / Inflectra)

Definitions and Form Fields

Combination therapy (methotrexate) capture

Combination therapyIs infliximab being used in combination with methotrexate? Options captured on the form: YES or NO. If NO, form requests an explanation.

Required supporting detailIf 'NO' is selected, provider must explain reason for not using methotrexate on the form.

Location on formCombination therapy checkbox appears in the DRUG INFORMATION section immediately after diagnosis and member weight fields.

Use for medical necessityConcomitant methotrexate use (yes/no) is collected to support medical necessity determination for outpatient infliximab administration.

Documentation attachmentExplanation provided when NO is checked should be included with other pertinent clinical attachments (date of last infusion, prior therapies tried/failed).

Background

Infliximab and its biosimilars are used to treat multiple immune-mediated disorders captured on the authorization form, including ankylosing spondylitis, non-infectious uveitis, juvenile idiopathic (rheumatoid) arthritis, Crohn’s disease, ulcerative colitis, psoriatic arthritis, and rheumatoid arthritis. The form collects indication, disease severity, prior therapies tried and failed, member weight, and whether infliximab is being used in combination with methotrexate to support medical necessity decisions for outpatient injectable administration. The policy distinguishes between preferred products (Avsola Q5121, Inflectra Q5103) and non-preferred products (Remicade J1745, Renflexis Q5104), and requires documentation of failure, intolerance, or contraindication to both preferred products when a non-preferred product is requested, except for Medicare members established on a non-preferred therapy.

OpenPayer

Outpatient Medical Injectable Infliximab Authorization Request Form

Coverage Criteria

Coding and Billing Codes

Provider Actions and Submission Requirements

Definitions and Form Fields

Background

J1745	Remicade
Q5104	Renflexis

Q5121	Avsola
Q5103	Inflectra