Medicare AdvantagePrior AuthMedium impact
MA08.019o, Intravenous Infliximab and Related Biosimilars
Independence Blue Cross·Gastroenterology, Rheumatology, Dermatology·Pharmacy
Effective date
Apr 21, 2025
We identified it
Jun 19, 2026
Summary
Medicare Advantage updated the medical necessity criteria for intravenous infliximab and related biosimilar drugs. This affects prior authorization requirements and coverage decisions for these expensive specialty medications used primarily for inflammatory conditions.
Action Required
By April 21, 2025: Billing team must review updated medical necessity criteria for infliximab and biosimilar infusions. Update prior authorization workflows to align with new Medicare Advantage requirements. Providers must ensure documentation meets revised criteria before submitting claims. Claims not meeting updated medical necessity standards will be denied.