MedicaidPrior AuthHigh impact
Preferred Infliximab Products - Inflectra (infliximab-dyyb) (Revised)
Humana·SC · Rheumatology, Gastroenterology, Dermatology +1 more·Medicaid
Effective date
Jul 1, 2024
We identified it
Jul 2, 2026
Summary
Humana Medicaid (South Carolina) updated its prior authorization policy for Inflectra (infliximab-dyyb), a TNF-alpha inhibitor biosimilar, establishing coverage criteria across seven indications including rheumatoid arthritis, Crohn's disease, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, and fistulizing Crohn's disease. The policy requires prior therapy/contraindication/intolerance to conventional therapies before approval and prohibits combination therapy with other biologics. Billing teams must implement prior authorization requirements and verify member eligibility against specific diagnostic and treatment history criteria before claims submission.
Action Required
By July 1, 2024 (retroactive - implement immediately): Billing team must configure prior authorization requirement for HCPCS code J1745 (Infliximab, infliximab-dyyb, for intravenous use) for all Medicaid-SC claims. Update billing software to require documented evidence of: (1) confirmed diagnosis matching one of seven covered indications; (2) member age requirements met; (3) prior therapy/contraindication/intolerance to specified conventional therapies; (4) NO concurrent biologic therapy (Cosentyx, Enbrel, adalimumab, Kevzara, Remicade). Modify claim submission workflow to flag any claims lacking this documentation. Train providers and billing staff to collect and submit required medical necessity documentation with all prior auth requests. Failure to obtain prior authorization before administration will result in claim denials on Medicaid-SC plans.