CommercialPrior AuthHigh impact
Infliximab (CPB 0341, reviewed 2026-07-21)
Aetna·Rheumatology, Gastroenterology, Dermatology +5 more·Medical Policy
Effective date
Jul 21, 2026
We identified it
Aug 15, 2026
Summary
Aetna has updated its Infliximab (CPB 0341) clinical policy effective 2026-07-21, establishing comprehensive coverage criteria for multiple infliximab biosimilar products across 10+ indications including rheumatoid arthritis, Crohn's disease, psoriasis, and other inflammatory conditions. The policy requires precertification for all commercial plans, mandates specific prescriber specialties, and enforces strict clinical trial requirements before approval—particularly for RA, where patients must fail conventional synthetic drugs or biologics first.
Action Required
Immediately: Billing team must implement precertification requirement for ALL infliximab products (Remicade, Renflexis, Avsola, Inflectra, Zymfentra) on Aetna commercial plans. Update billing system to flag all infliximab claims requiring precertification call to (866) 752-7021 or fax (888) 267-3277. Providers must verify: (1) prescriber specialty matches indication (e.g., rheumatologist for RA, gastroenterologist for Crohn's); (2) clinical trial requirements are met (e.g., prior NSAID failures for ankylosing spondylitis, prior biologic use for RA, prior conventional synthetic drug failures); (3) for RA specifically, biomarker testing (RF, anti-CCP, or both with CRP/ESR) is documented; (4) required combination therapy with methotrexate or leflunomide (or documented clinical reason for omission). Submit Statement of Medical Necessity (SMN) precertification forms with claims. Claims lacking precertification approval will be denied. Update encounter templates to capture specialty verification, prior therapy documentation, and biomarker results. Coordinate with specialty pharmacy for site-of-care compliance.