MedicaidPrior AuthHigh impact
Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq), Remicade (infliximab), unbranded Infliximab (Revised)
Humana·KY · Rheumatology, Gastroenterology, Dermatology +2 more·Medicaid
Effective date
Jan 1, 2024
We identified it
Jul 2, 2026
Summary
This policy establishes prior authorization requirements for non-preferred infliximab products (Renflexis, Avsola, Remicade, unbranded infliximab) under Kentucky Medicaid. Coverage is limited to seven specific indications with defined clinical criteria, including failure on preferred agent Inflectra. All infusions require documented failure or intolerance to Inflectra before approval.
Action Required
IMMEDIATE (retroactive to 2024-01-01): Billing and clinical teams must implement prior authorization requirements for all infliximab infusions billed to Kentucky Medicaid. 1) Update billing system to automatically route all infliximab claims (J1745, J1746, J1100) to prior auth queue before submission. 2) Clinical team must verify member meets ALL criteria for the specific indication (RA requires Criteria 1-4 including methotrexate co-therapy; GI indications require failure/intolerance with Inflectra first-line). 3) Providers must document: diagnosis severity (moderate-to-severe), prior Inflectra trial results, symptom control failure/intolerance, and contraindication reasons if methotrexate omitted. 4) Denial risk is HIGH without prior auth approval. Claims will be denied retroactively if submitted without documented approval. 5) For pediatric Crohn's/UC (ages 6-17), ensure member age is within specified range or claim will be denied. 6) Review all outstanding 2024-2025 infliximab claims for Kentucky Medicaid members and reprocess with prior auth if not previously obtained.