MedicaidPrior AuthHigh impact
Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq), Remicade (infliximab), unbranded Infliximab (Revised)
Humana·SC · Rheumatology, Gastroenterology, Dermatology +1 more·Medicaid
Effective date
Jul 1, 2024
We identified it
Jul 2, 2026
Summary
This is a Prior Authorization policy for non-preferred infliximab biosimilars (Renflexis, Avsola, Remicade, unbranded infliximab) under South Carolina Medicaid, effective July 1, 2024. The policy requires prior authorization before these medications can be covered for seven FDA-approved indications (rheumatoid arthritis, Crohn's disease, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, and fistulizing Crohn's disease). All members must demonstrate failure or intolerance with Inflectra (the preferred biosimilar) before these non-preferred alternatives are approved.
Action Required
By July 1, 2024: Billing and clinical teams must implement prior authorization requirements for all infliximab product claims (Renflexis, Avsola, Remicade, unbranded infliximab) under South Carolina Medicaid. (1) Update billing software to flag all J1100, J1159, and J1160 claims for mandatory prior authorization. (2) Providers must document in encounter notes that the member failed to achieve symptom control or has intolerance with Inflectra (the preferred agent) before submitting claims for non-preferred products. (3) Front desk/prior authorization staff must verify member meets age requirements and has appropriate diagnosis for one of seven covered indications before submission. (4) For rheumatoid arthritis cases, confirm member is on concomitant methotrexate therapy (unless contraindicated). (5) Clinical staff must screen for black box warning contraindications (active TB, clinically important active infections, pregnancy/lactation, demyelinating disease, moderate-to-severe heart failure, malignancies) and document screening in medical record. Claims submitted without prior authorization or missing required documentation of Inflectra failure will be denied by South Carolina Medicaid.