MedicaidPrior AuthHigh impact
Preferred Infliximab Products - Inflectra (infliximab-dyyb) (Revised)
Humana·KY · Rheumatology, Gastroenterology, Pediatrics +1 more·Medicaid
Effective date
Jan 1, 2024
We identified it
Jul 2, 2026
Summary
Humana Medicaid-Kentucky has revised its prior authorization policy for Inflectra (infliximab-dyyb), a biosimilar TNF-inhibitor, effective January 1, 2024 (last revised June 24, 2026). The policy establishes specific clinical criteria for coverage across seven indications: rheumatoid arthritis, Crohn's disease (adult and pediatric, fistulizing and non-fistulizing), ulcerative colitis (adult and pediatric), ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis. All approvals require prior authorization and exclude concurrent use with other biologics.
Action Required
By January 1, 2024 (retroactive—verify current claims): Billing and prior authorization teams must implement mandatory prior authorization requirement for Inflectra (HCPCS J1745) for all Humana Medicaid-Kentucky members. Update billing system to: (1) Route all Inflectra claims for prior auth review; (2) Verify member meets indication-specific criteria (documented diagnosis, age requirements, prior therapy/contraindication history, and biologic exclusion); (3) Reject claims lacking documentation of prior DMARD or NSAID trials as clinically appropriate; (4) Flag and deny any claims showing concurrent biologic therapy (e.g., Enbrel, Remicade, adalimumab products, Cosentyx, Kevzara). Providers must document clinical rationale on prior auth requests. Claims submitted without prior authorization will be denied. Ensure EMR/EHR templates capture required clinical history for all seven indications. Train front-desk and authorization staff on this biosimilar-specific policy.