Attention Section 60 – Medical Supplies and Durable Medical Equipment (DME) Providers: Billing of Infliximab

Jul 12, 2022

Attention Section 60 – Medical Supplies and Durable Medical Equipment (DME) Providers: Billing of Infliximab

Effective July 13, 2022, the Department will require Section 60 providers to obtain a prior authorization (PA) before delivering J1745 (injection, infliximab, excludes biosimilar, 10mg). In addition, the Department will add Q5121 (injection, infliximab-axxq, biosimilar, (avsola), 10mg) and Q5104 (injection, infliximab-abda, biosimilar, (renflexis), 10mg) to Section 60 contracts without a PA requirement, which are both biosimilar equivalents to J1745.

The Department will approve a PA for J1745 if the member has documented failure of Q5121 and Q5104 due to lack of efficacy, intolerable side effects to Q5121 and Q5104, or clinical exceptions. Clinical exceptions include the presence of a condition that prevents usage of J1745 or a significant drug interaction between another drug and J1745.

Providers shall use the “J1745 PA criteria sheet that the Department will upload to the Authorizations and Referrals folder on the Health PAS Online Portal before July 13, 2022.

Please contact your Provider Relations Specialist with questions.