CORRECTION: Attention Section 60 – Medical Supplies and Durable Medical Equipment Providers: Upcoming Changes - Billing of Infliximab

Jul 13, 2022

CORRECTION: Attention Section 60 – Medical Supplies and Durable Medical Equipment Providers: Upcoming Changes - Billing of Infliximab

The e-message sent on July 12, 2022, included an incorrect link for the J1745 PA criteria sheet. The correct pathway is below.

Effective July 13, 2022, the Department will require Section 60 – Medical Supplies and Durable Medical Equipment (DME) 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 should use the J1745 PA criteria sheet now available on the Health PAS Online Portal by following this pathway: MaineCare Information>Prior Authorizations>Manual, Forms, and Criteria Sheets under Section 60.

Please contact your Provider Relations Specialist with questions.