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Inflectra Preferred Therapy for Medicare Advantage Members

Audience: Par specialty providers that prescribe Infliximab products

Our updated 2018 infliximab drug policy names the biosimilar Inflectra as the preferred infliximab product for all lines of business (Commercial, Exchange, Essential Plan, Child Health Plus and Medicaid Managed Care) except Medicare Advantage.

Since the policy update, of our roughly 1,800 members who require treatment, 790 of them have been effectively treated with Inflectra. Many were new to therapy, but one-fifth (20 percent) of these individuals were safely transitioned from the innovator product, Remicade®. Together with your help, we have been able to save our community more than $11 million.

Effective February 15, 2021, this change will apply to all lines of business, including Medicare Advantage.

Inflectra will be the preferred therapy for new starts when infliximab is used to treat rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, plaque psoriasis, ulcerative colitis, and other compendium-supported diagnoses. Prior authorization will continue to be required for Remicade®, Renflexis® and Avsola™ for Medicare Advantage members with the additional requirement of justification as to why Inflectra is not appropriate therapy. Please note that prior authorization is not required on Inflectra for anyone. 

  • This change DOES NOT apply to members who are currently prescribed Remicade, Renflexis or Avsola; however, we strongly encourage you to consider switching your patients to Inflectra when you feel it is the right course of therapy. 
     
  • Most Medicare Advantage members have a 20-percent cost share for eligible Part B medications. These members could see immediate out-of-pocket savings if switched from Remicade to Inflectra due to its lower overall cost.

Prescribing and Billing Requirements

To ensure prescription accuracy and correct claim submissions, please follow the prescription and billing requirements outlined below: 

Prescription Requirements by Line of Business

Drug Name

Commercial &
Exchange

Medicaid Managed Care & Child Health Plus

Medicare

Inflectra
Preferred product

No prior
authorization
required

No prior
authorization
required

No prior
authorization
required

Remicade
Non-preferred product

Use of Inflectra
required for
new starts only

Use of Inflectra
required for
new starts only

Use of Inflectra
required for
new starts only

Renflexis

Non-preferred product

Avsola

Non-preferred product

Inflectra Billing Requirements

Q Code:

  • Q5103: injection, infliximab-dyyb biosimilar, 10mg

NDC:

  • 11-digit: 00069-0809-01

Site of Service Options:

  • Physician office
  • Home infusion
  • Hospital outpatient department


Please share this important information with your billing office/service and anyone within your practice who should be aware.

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Category

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Pharmacy

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