CurrentPremera BluecrossPolicy 5.01.564

Pharmacotherapy of Miscellaneous Autoimmune Diseases

Consolidates medical necessity and site-of-service review criteria for numerous biologic and pharmacologic agents across autoimmune diseases; specifies which drugs require preapproval, benefit management (pharmacy vs medical), site-of-service rules, diagnostic and prior-therapy requirements, and coding updates.

Policy Summary

PayerPremera Bluecross

PolicyPharmacotherapy of Miscellaneous Autoimmune Diseases

Policy CodePolicy 5.01.564

Change TypeMultiple coding, formulary, and clinical criteria updates (additions/revisions/removals)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain preapproval and document required diagnostics, prior therapy trials/intolerances, and specialist consultation per the policy when requesting covered biologic or specialty therapies.

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for multiple drugs over time (Rystiggo, Cosentyx, Tarpeyo, Rezurock, Bimzelx, Voyxact, Imaavy, Otezla XR, etc.).

Updated formulary statuses for multiple adalimumab and infliximab products with NDC-specific preferred/non-preferred designations.

Added and replaced multiple HCPCS codes (e.g., J9333, J9334, Q5135, J9038, C9305, J9256).

Clarified site-of-service review applicability and exceptions (e.g., Alaska fully-insured members exemption per Alaska HB 226; exceptions for CRS).

Changed Tarpeyo urine protein-to-creatinine ratio threshold from >=1.5 g/g to >=0.8 g/g or proteinuria >=1 g/day.

Updated CRS coverage criteria to be medically necessary if treatment-induced and grade 3-4, not limited to CAR-T products.

Removed Idacio (adalimumab-aacf) from policy after being removed from market.

Updated Benlysta SC age requirement for active lupus nephritis from 18 years to 5 years and older.

multipleIndications covered (listed in part)

numerousDrugs subject to SOS review in part

manyHCPCS/J-code updates

2Key lab thresholds (UPCR, eGFR)

multipleSpecialist requirements noted

CURRENTStatus

Coverage Summary

Medical‑Necessity Criteria (by indication / drug)

Site of Service (SOS) Medical Necessity

Site of Service (SOS) Medical Necessity criteria applies ONLY to medical benefit reviews. SOS Medical Necessity criteria does NOT apply to Alaska fully-insured members; refer to the infusion and injection drug Medical Necessity criteria only. Please contact Customer Service for more information.

We will review specific intravenous (IV) and injectable drugs for medical necessity for all ages. For individuals aged 13 and older, we also will review the site of service for medical necessity. Site of service is defined as the location where the drug is administered, such as a hospital-based outpatient setting, an infusion center, a physician's office, or at home.

Hidradenitis Suppurativa (HS) - First-line TNF-α Antagonists

Policy Summary

PayerPremera Bluecross

PolicyPharmacotherapy of Miscellaneous Autoimmune Diseases

Policy CodePolicy 5.01.564

Change TypeMultiple coding, formulary, and clinical criteria updates (additions/revisions/removals)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain preapproval and document required diagnostics, prior therapy trials/intolerances, and specialist consultation per the policy when requesting covered biologic or specialty therapies.

SourceLink

On This Page

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.

Adalimumab-aaty (Yuflyma unbranded) SC; Adalimumab-adaz (Hyrimoz unbranded) SC; Adalimumab-adbm (Cyltezo unbranded) SC; Adalimumab-ryvk (Simlandi unbranded) SC; Simlandi (adalimumab-ryvk) SC; Yuflyma (adalimumab-aaty) SC may be considered medically necessary for the treatment of hidradenitis suppurativa when ALL of the following are met:

• The individual is aged >= 12 years

• Has tried at least one other therapy (e.g., intralesional or oral corticosteroids, systemic antibiotics)

• Medication is prescribed by or in consultation with a dermatologist

Note: This medical necessity criteria does not apply to one Open formulary (Formulary ID: 6062; Rx Plan F1). The criteria for members with this custom Open formulary plan can be found in policy 5.01.647 Medical Necessity Criteria for Custom Open Formulary. Please check the member Plan booklet or member ID card to determine applicability.

HS - IL-17 Antagonists (First-line)

Hidradenitis Suppurativa (HS) - IL-17 Antagonists (First-line)

Cosentyx (secukinumab) SC may be considered medically necessary for the treatment of hidradenitis suppurativa when ALL of the following are met:

• The individual is aged >= 18 years

• Has tried at least one other therapy (e.g., intralesional or oral corticosteroids, systemic antibiotics)

• Medication is prescribed by or in consultation with a dermatologist

HS - TNF-α Antagonists (Second-line)

The following adalimumab products may be considered medically necessary for the treatment of hidradenitis suppurativa when ALL of the following are met:

• The individual is aged >= 12 years

• Has tried at least one other therapy (e.g., intralesional or oral corticosteroids, systemic antibiotics)

• Has had an inadequate response or intolerance to ALL the following agents:

o Adalimumab-adbm (Cyltezo unbranded)

o Adalimumab-adaz (Hyrimoz unbranded)

o Simlandi (adalimumab-ryvk) OR adalimumab-ryvk (Simlandi unbranded)

o Yuflyma (adalimumab-aaty) OR adalimumab-aaty (Yuflyma unbranded)

• Medication is prescribed by or in consultation with a dermatologist

Note: This medical necessity criteria does not apply to one Open formulary (Formulary ID: 6062; Rx Plan F1). See policy 5.01.647 for that plan.

HS - IL-17 Antagonists (Second-line) - Bimzelx

Bimzelx (bimekizumab-bkzx) SC may be considered medically necessary for hidradenitis suppurativa when ALL of the following are met:

• The individual meets criteria for HS requiring biologic therapy (e.g., inadequate control with standard therapies)

• Medication is prescribed by or in consultation with a dermatologist

• Other first-line biologic options have been considered or trialed as clinically appropriate (per formulary sequencing where applicable)

Immunoglobulin G4-Related Disease (IgG4-RD) - Uplizna

Immunoglobulin G4-Related Disease (IgG4-RD) - Uplizna (inebilizumab)

Uplizna (inebilizumab-cdon) IV may be considered medically necessary (medical benefit) for IgG4‑related disease when ALL of the following are met:

• Biopsy showing histopathologic features consistent with IgG4‑related disease OR other compelling clinical and radiologic evidence of IgG4‑RD affecting one or more organs

• When biopsy is available, at least one of the following pathologic features is present (n_of = 1):

o Dense lymphoplasmacytic infiltrate

o Storiform-type fibrosis

o Obliterative phlebitis

• Involvement of at least one of the following organs: pancreas, salivary glands, lacrimal glands, biliary tree, retroperitoneum, kidneys, lungs, or other typical organ sites

• Prior trial of and inadequate response, intolerance, or contraindication to a glucocorticoid regimen OR intolerance/contraindication to glucocorticoids

• Medication is prescribed by or in consultation with a rheumatologist, immunologist, or other appropriate specialist experienced in managing IgG4‑RD

• Site of service reviewed per SOS Medical Necessity when applicable (IV infusions)

Systemic Lupus Erythematosus (SLE) & Lupus Nephritis - Benlysta

Systemic Lupus Erythematosus (SLE) & Lupus Nephritis - Benlysta (belimumab)

Benlysta (belimumab) may be considered medically necessary as add-on therapy for active systemic lupus erythematosus when ALL of the following are met:

• Diagnosis of active SLE

• Medication is prescribed by or in consultation with a rheumatologist

• Age criteria as per product labeling (adult or pediatric age indications)

For active lupus nephritis (subnode):

• Active lupus nephritis confirmed by biopsy and nephrology evaluation

• Medication is prescribed by or in consultation with a nephrologist or rheumatologist

• Age >= 5 years for labeled pediatric use where applicable

Lupkynis (voclosporin) - lupus nephritis

Lupkynis (voclosporin) - Lupus Nephritis

Lupkynis (voclosporin) may be considered medically necessary for the treatment of lupus nephritis when ALL of the following are met:

• Diagnosis of active lupus nephritis confirmed by kidney biopsy

• Patient is >= 18 years of age

• Medication is prescribed by or in consultation with a nephrologist or rheumatologist

• Used in combination with standard induction therapy (e.g., mycophenolate mofetil and corticosteroids) per labeled regimen

Saphnelo (anifrolumab-fnia) - SLE

Saphnelo (anifrolumab-fnia) IV (type I interferon receptor antagonist) may be considered medically necessary for systemic lupus erythematosus when ALL of the following are met:

• Diagnosis of moderate to severe SLE for which anifrolumab is indicated

• Medication is prescribed by or in consultation with a rheumatologist

• Key exclusions: severe active central nervous system lupus or severe active lupus nephritis when contraindicated by labeling

• Non-concurrency: follow labeling for concomitant therapies and avoid disallowed concurrent biologics per formulary policy

Pyoderma Gangrenosum - First Line (TNF-α Adalimumab products)

Adalimumab products (e.g., branded and biosimilar adalimumab agents managed under pharmacy benefit) may be considered medically necessary for pyoderma gangrenosum when ALL of the following are met:

• Diagnosis of pyoderma gangrenosum confirmed by dermatologist

• Medication is prescribed by or in consultation with a dermatologist

• Prior trial of and inadequate response or intolerance to conventional therapies (e.g., topical and systemic corticosteroids, systemic immunosuppressants)

Pyoderma Gangrenosum - TNF-α Antagonists (Infliximab products) - Second Line

Infliximab products (Avsola, Inflectra, Infliximab [Janssen], Remicade, Renflexis) administered as medical benefit may be considered medically necessary for pyoderma gangrenosum when ALL of the following are met:

• Diagnosis confirmed by a dermatologist

• Medication is prescribed by or in consultation with a dermatologist

• Inadequate response or intolerance to first-line therapy with adalimumab products

• When multiple infliximab biosimilars are available, documentation of inadequate response/intolerance should reflect an adequate trial of the specific infliximab agent used prior to switching to an alternative infliximab product

• Site of service reviewed per SOS Medical Necessity when applicable (IV infusions)

Uveitis - First Line (TNF-α Adalimumab products)

Adalimumab products may be considered medically necessary for noninfectious uveitis when ALL of the following are met:

• The individual is aged >= 2 years (or per product labeling)

• Diagnosis of noninfectious uveitis confirmed by an ophthalmologist

• Prior trial of adequate corticosteroid therapy (topical/periocular/systemic) and at least one conventional immunosuppressive agent unless contraindicated or not tolerated

• Medication is prescribed by or in consultation with an ophthalmologist

Uveitis - Avsola/Inflectra and Infliximab/Remicade/Renflexis (Second-line / medical benefit infliximabs)

Infliximab products (Avsola, Inflectra, Remicade, Renflexis, unbranded infliximab) administered as medical benefit may be considered medically necessary for noninfectious uveitis when ALL of the following are met:

• Diagnosis confirmed by an ophthalmologist

• Medication is prescribed by or in consultation with an ophthalmologist

• Inadequate response or intolerance to first-line adalimumab therapy or other indicated agents

• When sequencing among infliximab biosimilars, an adequate trial of the specific infliximab formulation tried should be documented prior to deeming all infliximab products ineffective

• Site of service reviewed per SOS Medical Necessity when applicable (IV infusions)

Giant Cell Arteritis - Tocilizumab products and Rinvoq

Giant Cell Arteritis

Tocilizumab products (Actemra IV/SC and biosimilars) and Rinvoq (upadacitinib) may be considered medically necessary for giant cell arteritis when ALL of the following are met:

• Diagnosis of giant cell arteritis established by appropriate clinical evaluation (temporal artery biopsy or imaging where indicated)

• Patient has required initiation of or ongoing glucocorticoid therapy; tocilizumab is used to allow glucocorticoid tapering or for patients with relapsing disease

• Medication is prescribed by or in consultation with a rheumatologist

• Site of service reviewed per SOS Medical Necessity when applicable (IV infusions)

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) - Vyvgart Hytrulo

Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) SC (medical benefit + SOS where applicable) may be considered medically necessary for CIDP when ALL of the following are met:

• Age >= 18 years

• Clinical features consistent with CIDP (progressive or relapsing symmetric proximal and distal weakness with sensory involvement and reduced/absent reflexes)

• Diagnosis supported by electrodiagnostic testing meeting AAN/CIFA criteria for demyelination

• At least ONE supportive test present (any of):

o Cerebrospinal fluid with albuminocytologic dissociation (elevated protein with <10 WBC)

o MRI showing nerve-root or plexus enhancement or thickening

o Nerve biopsy supportive of demyelination

• Prior trial and inadequate response or intolerance to IVIG therapy OR documented contraindication to IVIG

• Medication is prescribed by or in consultation with a neurologist experienced in neuromuscular disorders

• Site of service reviewed per SOS Medical Necessity when applicable

C3 Glomerulopathy (C3G) / Fabhalta (iptacopan) and IgAN-related criteria

C3 Glomerulopathy (C3G) and Primary IgA Nephropathy (IgAN) - Fabhalta (iptacopan) and related renal criteria

Fabhalta (iptacopan) may be considered medically necessary for C3 glomerulopathy (C3G) when ALL of the following are met:

• Biopsy‑proven C3 glomerulopathy (kidney biopsy demonstrating predominant C3 deposition)

• Urine protein-to-creatinine ratio (UPCR) >= 1 g/g

• Estimated glomerular filtration rate (eGFR) >= 30 mL/min/1.73 m2

• Trial of an ACE inhibitor or ARB for at least 4 weeks at maximally tolerated dose AND inadequate response OR documented intolerance to ACEi/ARB (one-of branch)

• Medication is prescribed by or in consultation with a nephrologist

• Exclusions / cautions: rapidly progressive glomerulonephritis with crescentic disease and extensive interstitial fibrosis/tubular atrophy (>50%) may be excluded per specialist judgment

For Fabhalta considered for primary IgA nephropathy (IgAN) where applicable:

• UPCR and eGFR thresholds and ACEi/ARB trial or intolerance requirements mirror those above (e.g., UPCR >= 1 g/g; eGFR >= 30 mL/min/1.73 m2)

• Medication is prescribed by or in consultation with a nephrologist

Note: General renal baseline criteria (UPCR, eGFR, ACEi/ARB trial) are required for initiation and are applied across renal indications in this policy.

Vyvgart Hytrulo - consolidated neurologic fragments

Vyvgart Hytrulo - consolidated neurologic criteria (repeated fragments consolidated)

For neurologic demyelinating or autoimmune indications where Vyvgart Hytrulo is considered, include ALL of the following when applicable:

• Age and indication-specific age thresholds (e.g., CIDP >=18 years)

• Diagnosis supported by appropriate diagnostic criteria and testing (electrodiagnostic studies, CSF, MRI, or nerve biopsy as appropriate); supportive testing examples include CSF with elevated protein and <10 WBC, MRI nerve-root enhancement, or nerve biopsy supportive of demyelination

• Prior trial and inadequate response or intolerance to IVIG where IVIG is standard therapy, or documented contraindication to IVIG

• Medication prescribed by or in consultation with a neurologist experienced in neuromuscular diseases

• Site of service reviewed per SOS Medical Necessity when applicable

Cytokine Release Syndrome (CRS) - IL-6 antagonists tocilizumab products and anakinra

Cytokine Release Syndrome (CRS) - IL-6 antagonists and Anakinra

CRS requiring IL‑6 antagonists (tocilizumab products) or anakinra (Kineret) may be considered medically necessary when ALL of the following are met:

• CRS is grade 3 or 4 as evidenced by ALL of the following:

o Temperature >= 38 °C

o Hypotension requiring one or more vasopressors

o Hypoxia requiring high‑flow oxygen delivery (high‑flow nasal cannula, face mask, non‑rebreather, Venturi) OR positive pressure ventilation (CPAP, BiPAP, intubation, mechanical ventilation)

• Patient requires escalation of care and will be admitted to inpatient setting as soon as possible when indicated

• Site of service exceptions: inpatient or hospital-based outpatient infusion is medically necessary for grade 3–4 CRS per above criteria

NMOSD - Uplizna (inebilizumab) and Enspryng (satralizumab)

Neuromyelitis Optica Spectrum Disorder (NMOSD) - Uplizna and Enspryng

Uplizna (inebilizumab-cdon) and Enspryng (satralizumab-mwge) may be considered medically necessary for NMOSD when ALL of the following are met:

• Diagnosis of NMOSD with supporting core clinical characteristics (optic neuritis, transverse myelitis, area postrema syndrome, brainstem, diencephalic, or cerebral syndromes)

• AQP4‑IgG seropositivity when required per product labeling for certain approvals (document antibody status)

• History of relapses consistent with NMOSD or other disease activity metrics per specialist assessment

• Medication is prescribed by or in consultation with a neurologist experienced in NMOSD management

• EDSS or relapse thresholds applied per product labeling or specialist guidance where specified

Arcalyst (rilonacept) for DIRA

Arcalyst (rilonacept) for DIRA (Deficiency of Interleukin-1 Receptor Antagonist)

Arcalyst (rilonacept) may be considered medically necessary for DIRA when ALL of the following are met:

• Documentation of pathogenic mutation in IL1RN consistent with DIRA where available

• Patient weight >= 10 kg

• Medication prescribed by or in consultation with a rheumatologist, geneticist, or dermatologist experienced in rare autoinflammatory disorders

• Supportive testing (e.g., genetic testing) is recommended but may be optional depending on clinical context

Kineret (anakinra) - selected DIRA/CAPS/CRS criteria

Kineret (anakinra) for DIRA/CAPS/CRS

Kineret (anakinra) may be considered medically necessary for DIRA or CAPS when ALL of the following are met:

• Genetic testing confirming IL1RN mutation for DIRA when available (or strong clinical and family history supportive of diagnosis)

• For CRS: indication reserved for grade 3–4 CRS per CRS criteria above

• Medication prescribed by or in consultation with an appropriate specialist (rheumatologist, immunologist, or intensivist)

Ilaris (canakinumab) - periodic fever syndromes & Still's disease

Ilaris (canakinumab) for periodic fever syndromes and Still's disease

Ilaris (canakinumab) may be considered medically necessary for periodic fever syndromes (e.g., familial Mediterranean fever, TRAPS, HIDS/MKD) or systemic juvenile idiopathic arthritis/Still's disease when ALL of the following are met:

• Diagnosis confirmed by appropriate clinical and, when available, genetic testing

• Age thresholds and prescriber specialties per product labeling (typically pediatric rheumatologist or allergist/immunologist involvement)

Niktimvo (axatilimab) / Rezurock (belumosudil) / Ryoncil (remestemcel-L) - GVHD

GVHD-related therapies: Niktimvo, Rezurock, Ryoncil

Niktimvo (axatilimab-csfr), Rezurock (belumosudil), and Ryoncil (remestemcel-L-rknd) coverage criteria:

• Indication-specific prior therapy requirements apply (e.g., for chronic GVHD, failure of or intolerance to systemic corticosteroids and other lines as per labeling)

• Ryoncil: pediatric steroid-refractory acute GVHD — note pediatric dosing limits per product labeling

• Medication prescribed by or in consultation with an appropriate transplant specialist or hematologist/oncologist

Myasthenia Gravis (gMG) - Imaavy, Rystiggo, Uplizna, Vyvgart family

Myasthenia Gravis (gMG) - assorted agents (Imaavy, Rystiggo, Uplizna, Vyvgart family)

For generalized myasthenia gravis (gMG), coverage considerations across agents include ALL of the following where applicable:

• Documentation of antibody status (AChR-Ab or MuSK-Ab) when required by product labeling or to guide therapy

• Prior trials of pyridostigmine and at least one conventional immunosuppressive therapy unless contraindicated or not tolerated

• Prior biologic or complement inhibitor trials per product-specific requirements (e.g., prior complement inhibitor for subsequent therapies)

• Age thresholds per product labeling

• Non-concurrency rules: avoid concomitant use of certain biologics as specified by labeling and formulary guidance

• Prescriber requirement: neurology or neuromuscular specialist involvement is preferred

IgAN-specific agent criteria (Fabhalta, Filspari, Tarpeyo, Vanrafia, Voyxact)

IgAN-specific agents (Fabhalta, Filspari, Tarpeyo, Vanrafia, Voyxact)

Fabhalta (iptacopan) for primary IgA nephropathy (IgAN) — candidate criteria include:

• UPCR threshold typically >= 1 g/g (unless specified otherwise by drug labeling)

• eGFR threshold typically >= 30 mL/min/1.73 m2

• Trial of ACE inhibitor or ARB at maximally tolerated dose for at least 4 weeks with inadequate response OR documented intolerance to ACEi/ARB

• Prescribed by or in consultation with a nephrologist

Filspari (sparsentan), Tarpeyo (budesonide), Vanrafia (atrasentan), and Voyxact have individual UPCR/eGFR/dose/duration and prescriber requirements per their labeled indications (e.g., Filspari UPCR >=1.5 g/g; Tarpeyo UPCR >=0.8 g/g or proteinuria >=1 g/day) and should follow nephrologist oversight.

Coding

HCPCS / J-codes listed for covered agentsHCPCSCovered

J0129	Injection, infliximab-abda, biosimilar, 10 mg
J0139	Injection, belimumab, 10 mg
J0490	Injection, tocilizumab, 1 mg
J0491	Injection, tocilizumab, alternative code
J0638	Injection, efgartigimod alfa-fcab, 1 mg
J1438	Injection, anifrolumab-fnia, 1 mg
J1745	Injection, infliximab, 10 mg
J1823	Injection, rituximab biosimilar/rituximab, 10 mg
J2793	Injection, canakinumab, 1 mg
J3262	Injection, belimumab IV, 1 mg (alternate)

1–10 of 13

1/2

Drugs subject to site-of-service review (listed by brand and route)mixedCovered

Actemra IV	tocilizumab, intravenous
Avsola IV	infliximab-axxq, intravenous
Avtozma IV	tocilizumab-anoh, intravenous
Benlysta IV	belimumab, intravenous
Ilaris SC	canakinumab, subcutaneous
Inflectra IV	infliximab-dyyb, intravenous
Infliximab (Janssen) IV	unbranded infliximab, intravenous
Remicade IV	infliximab, intravenous
Renflexis IV	infliximab-abda, intravenous
Saphnelo IV	anifrolumab-fnia, intravenous

1–10 of 15

1/2

Adalimumab products (pharmacy benefit listings)mixedCovered

Adalimumab-aaty	Yuflyma (adalimumab-aaty)
Adalimumab-adaz	Hyrimoz (adalimumab-adaz)
Adalimumab-adbm	Cyltezo (adalimumab-adbm)
Adalimumab-ryvk	Simlandi (adalimumab-ryvk)
Simlandi	adalimumab-ryvk
Yuflyma	adalimumab-aaty
Abrilada	adalimumab-afzb
Adalimumab-aacf	Idacio unbranded (adalimumab-aacf)
Adalimumab-fkjp	Hulio (adalimumab-fkjp)
Amjevita	adalimumab-atto

1–10 of 16

1/2

Other specialty agents (by brand)mixedCovered

Lupkynis	voclosporin, oral - specialty agent listed
Saphnelo	anifrolumab-fnia, IV
Enbrel	etanercept, injectable
Riabni/Rituxan/Ruxience	rituximab and biosimilars, IV
Fabhalta	ubrogepant - specialty listing (if applicable)
Rinvoq	upadacitinib, oral
Vyvgart Hytrulo	efgartigimod alfa and hyaluronidase-qvfc, SC
Actemra	tocilizumab (brand)
Avsola	infliximab-axxq
Inflectra	infliximab-dyyb

1–10 of 20

1/2

HCPCS codes added/updatedHCPCS

Q5103	Infliximab biosimilar code Q5103
Q5104	Infliximab biosimilar code Q5104
Q5121	Biosimilar J-code listing Q5121
Q5133	Biosimilar code Q5133
Q5140	Biosimilar code Q5140
Q5141	Biosimilar code Q5141
Q5142	Biosimilar code Q5142
Q5143	Biosimilar code Q5143
Q5144	Biosimilar code Q5144
Q5145	Biosimilar code Q5145

1–10 of 12

1/2

HCPCS codes added/updated (dates)HCPCS

J0129	Listed/updated - see policy effective date
J1745	Infliximab code updated
J9332	Anifrolumab-related code added/updated

NDC-based formulary updates (NDC-prefix entries)NDC

NDC 55513*	Prefix NDC update entry
NDC 83457*	Prefix NDC update entry
NDC 61314*	Prefix NDC update entry
NDC 00074*	Prefix NDC update entry

Additional single-code referencesmixed

Vyvgart

efgartigimod alfa-fcab (referenced across IV and SC presentations)

Infliximab-related J-codes includedHCPCSCovered

J1745	Injection, infliximab, 10 mg (Remicade)
J0129	Injection, infliximab-abda, biosimilar, 10 mg (Renflexis)
J0490	Injection, tocilizumab (used for Actemra/Avtozma/Tofidence/Tyenne dosing references)

Unclassified / miscellaneous HCPCSHCPCS

J3590

Unclassified biologic drug - use with appropriate drug name on claim

Provider Actions & Requirements

Note

OpenPayer

Pharmacotherapy of Miscellaneous Autoimmune Diseases

Coverage Summary

Medical‑Necessity Criteria (by indication / drug)

Coding

Provider Actions & Requirements

Revision History