All PlansPrior AuthHigh impact
Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™); Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra); infliximab; infliximababda
BCBS Tennessee·TN · Gastroenterology, Rheumatology, Dermatology +5 more·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
This is a comprehensive medical policy for infliximab products (Remicade, Avsola, Inflectra, Renflexis, Zymfentra) covering multiple indications including Crohn's disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, and compendial uses. The policy establishes prior authorization requirements, documentation standards, prescriber specialty requirements, and coverage criteria. The policy is marked 'Do Not Implement until 10/31/26,' indicating this is future guidance not yet in effect.
Action Required
By October 31, 2026: Billing team must implement prior authorization requirements for all infliximab products across approved indications. Update billing system to enforce: (1) 12-month authorization periods for CD, UC, and RA; (2) prescriber specialty verification (gastroenterologist for GI indications, rheumatologist for arthritis conditions, dermatologist for dermatologic conditions, etc.); (3) required documentation submission based on indication type (biomarker testing for RA, BSA measurement for psoriasis, previous medication trials, clinical response documentation). Providers must document positive clinical response for continuation requests. Update encounter forms to capture required clinical documentation per indication. Configure system to reference the Step Therapy Guide for specialty medications. Ensure claims without proper prior authorization and documentation will be denied. This requires coordination between billing, prior authorization, and provider education teams.