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Infliximab: Remicade®; Inflectra™; Renflexis™; Avsola™; Infliximab*

Policy Number: PH-0104

 

Intravenous

 

Last Review Date: 10/03/2023

Date of Origin: 07/20/2010

Dates Reviewed:  09/2010, 12/2012, 2/2011, 03/2011, 06/2011, 09/2011, 10/2011, 12/2011, 03/2012, 06/2012, 09/2012, 11/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 06/2015, 09/2015, 12/2015, 03/2016, 06/2016, 09/2016, 12/2016, 03/2017, 06/2017, 09/2017, 12/2017, 03/2018, 06/2018, 10/2018, 04/2019, 07/2019, 07/2020, 08/2021, 02/2022, 10/2022, 10/2023

FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill.

  1. Length of Authorization

Coverage will be provided for 12 months and may be renewed unless otherwise specified.

  • Therapy for the Management of Immune-Checkpoint Inhibitor Related Toxicity and GVHD may not be renewed.
  1. Dosing Limits
  1. Quantity Limit (max daily dose) [NDC Unit]:

Loading Dose:

  • Remicade/Infliximab 100 mg single-dose vial: 6 vials at weeks 0, 2, 6 (18 vials total)
  • Inflectra 100 mg single-dose vial: 6 vials at weeks 0, 2, 6 (18 vials total)
  • Renflexis 100 mg single-dose vial: 6 vials at weeks 0, 2, 6 (18 vials total)
  • Avsola 100 mg single-dose vial: 6 vials at weeks 0, 2, 6 (18 vials total)

Maintenance Dose:

  • Remicade/Infliximab 100 mg single-dose vial: 11 vials every 4 weeks
  • Inflectra 100 mg single-dose vial: 11 vials every 4 weeks
  • Renflexis 100 mg single-dose vial: 11 vials every 4 weeks
  • Avsola 100 mg single-dose vial: 11 vials every 4 weeks
  1. Max Units (per dose and over time) [HCPCS Unit]:
  • Rheumatoid Arthritis: 40 billing units at weeks 0, 2, 6, then 120 billing units every 28 days
  • Ankylosing Spondylitis: 60 billing units at weeks 0, 2, 6, then 60 billing units every 42 days
  • Crohn’s Disease & Ulcerative Colitis: 60 billing units at weeks 0, 2, 6 then 120 billing units every 56 days
  • Psoriatic Arthritis, Plaque Psoriasis, Behcet’s Uveitis: 60 billing units at weeks 0, 2, 6 then 60 billing units every 56 days
  • Management of Immune Checkpoint Inhibitor Related Toxicity: 60 billing units at weeks 0 & 2; no maintenance dosing
  • Acute GVHD: 120 billing units at weeks 0, 1, 2, 3; no maintenance dosing
  1. Initial Approval Criteria 1-4

Depending on member benefits, additional criteria may apply for coverage of this drug in an outpatient facility setting. Verify any Site of Service requirements with the member’s plan and refer to the Voluntary Site of Service Policy or the Mandatory Site of Service Policy for additional information.

Coverage is provided in the following conditions:

For PEEHIP Members Only

  • Inflectra and Renflexis are the preferred infliximab products. Patients currently on Remicade, Infliximab*, or Avsola may complete their current course of treatment for the duration of the current precertification period; upon precertification renewal or restarting therapy, transition to a preferred product is required. Remicade, Infliximab*, and Avsola are non-covered for new to therapy members and will be non-covered for patients after their current precertification expires. *Unbranded product.

For Commercial Members Only

  • Remicade, Infliximab*, Inflectra and Avsola are the preferred infliximab products.  Patients must have failed, or have a contraindication, or intolerance to at least two of the preferred infliximab products prior to consideration of Renflexis. Patients who have been receiving Renflexis may continue therapy with that product.

*unbranded biologic

  • Patient has been evaluated and screened for the presence of hepatitis B (HBV) infection (i.e., HBsAg and anti-HBc) prior to initiating treatment; AND
  • Patient is up to date with all vaccinations, in accordance with current vaccination guidelines, prior to initiating therapy; AND
  • Patient is at least 18 years of age (unless otherwise specified); AND

Universal Criteria 1-4

  • Patient has been evaluated and screened for the presence of latent tuberculosis (TB) infection prior to initiating treatment and will receive ongoing monitoring for presence of TB during treatment; AND
  • Patient does not have an active infection, including clinically important localized infections; AND
  • Must not be administered concurrently with live vaccines or therapeutic infectious agents (i.e., BCG bladder instillation for bladder cancer, etc.); AND
  • Patient is not on concurrent treatment with another TNF-inhibitor, IL-inhibitor, biologic response modifier or other non-biologic agent (i.e., apremilast, abrocitinib, tofacitinib, baricitinib, upadacitinib, deucravacitnib, etc.); AND
  • Will not be used in patients with moderate or severe heart failure (i.e., New York Heart Association [NYHA] Functional Class III/IV) [Note: Only applies when doses >5mg/kg are used]; AND

Crohn’s Disease † Ф 1-4,11,13,23,38,75-78

Requirement for a 3 month trial of traditional therapies is waived if ONE of the following applies:

  • Patients with severe disease presenting with any of the following: recent surgery or hospitalization, anemia requiring blood transfusion, significant weight loss, fever, malnutrition, extraintestinal symptoms
  • Patients with first presentation requiring surgery
  • Patients with severe disease and unresponsive to high dose steroids OR immunosuppressive medications after 2 weeks
  • Patients unable to attain remission without continuous corticosteroids.
  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Documented moderate to severe disease; AND
  • Documented failure, contraindication, or ineffective response at maximum tolerated doses to a minimum (3) month trial of corticosteroids or immunomodulators (e.g., azathioprine, 6-mercaptopurine, or methotrexate)

Pediatric Crohn’s Disease † Ф 1-4,80

Requirement for a 3 month trial of traditional therapies is waived if ONE of the following applies:

  • Patients with severe disease presenting with any of the following: recent surgery or hospitalization, anemia requiring blood transfusion, significant weight loss, fever, malnutrition, extraintestinal symptoms
  • Patients with first presentation requiring surgery
  • Patients with severe disease and unresponsive to high dose steroids OR immunosuppressive medications after 2 weeks
  • Patients unable to attain remission without continuous corticosteroids.
  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Patient is at least 6 years of age; AND
  • Documented moderate to severe active disease; AND
  • Documented failure, contraindication, or ineffective response at maximum tolerated doses to a minimum (3) month trial of corticosteroids or immunomodulators (e.g., azathioprine, etc.)

Ulcerative Colitis † 1-4,20,81-83, 91,93

Requirement for a 3 month trial of traditional therapies is waived if ONE of the following applies:

  • Patients with severe disease presenting with any of the following: recent surgery or hospitalization, anemia requiring blood transfusion, significant weight loss, fever, malnutrition, extraintestinal symptoms
  • Patients with first presentation requiring surgery
  • Patients with severe disease and unresponsive to high dose steroids OR immunosuppressive medications after 2 weeks
  • Patients unable to attain remission without continuous corticosteroids.
  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Documented moderate to severe active disease; AND
  • Documented failure or ineffective response to a minimum (3) month trial of conventional therapy [aminosalicylates, corticosteroids or immunomodulators (e.g., azathioprine, 6-mercaptopurine, or methotrexate)] at maximum tolerated doses, unless there is a contraindication or intolerance to use

Pediatric Ulcerative Colitis † Ф 1-4,84

Requirement for a 3 month trial of traditional therapies is waived if ONE of the following applies:

  • Patients with severe disease presenting with any of the following: recent surgery or hospitalization, anemia requiring blood transfusion, significant weight loss, fever, malnutrition, extraintestinal symptoms
  • Patients with first presentation requiring surgery
  • Patients with severe disease and unresponsive to high dose steroids OR immunosuppressive medications after 2 weeks
  • Patients unable to attain remission without continuous corticosteroids.
  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Patient is at least 6 years of age; AND
  • Documented moderate to severe active disease; AND
  • Documented failure or ineffective response to a minimum (3) month trial of conventional therapy [aminosalicylates, corticosteroids or immunomodulators (e.g., azathioprine, 6-mercaptopurine, or methotrexate)] at maximum tolerated doses, unless there is a contraindication or intolerance to use

Fistulizing Crohn’s Disease † 38,76

  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Patient has at least one draining fistula (i.e., enterovesical, enterocutaneous, enteroenteric, or enterovaginal fistulas) for at least 3 months

Rheumatoid Arthritis (RA) † 1-4,74,85, 91

  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Documented moderate to severe active disease; AND
  • Patient has had at least a 3 month trial and failed previous therapy with ONE oral disease modifying anti-rheumatic agent (DMARD) such as methotrexate, azathioprine, auranofin, hydroxychloroquine, penicillamine, sulfasalazine, leflunomide, etc.; AND
  • Used in combination with methotrexate (MTX) unless contraindicated

Psoriatic Arthritis (PsA) † 1-4,39,41,71

  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Documented moderate to severe active disease; AND
  • For patients with predominantly axial disease, a trial and failure of at least a 4-week trial of ONE non-steroidal anti-inflammatory agent (NSAID), unless use is contraindicated; OR
  • For patients with peripheral arthritis, dactylitis OR active enthesitis, a trial and failure of at least a 3 month trial of ONE oral disease-modifying anti-rheumatic agent (DMARD) such as methotrexate, azathioprine, sulfasalazine, hydroxychloroquine, etc.

Ankylosing Spondylitis (AS) † 1-4,19,73

  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Documented active disease; AND
  • Patient had an adequate trial and failure of at least TWO (2) non-steroidal anti-inflammatory agents (NSAIDs) over 4 weeks (in total), unless use is contraindicated

Plaque Psoriasis (PsO) † 1-4,67-69,79,88,89

  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Documented moderate to severe chronic disease for at least 6 months with at least one of the following:
    • Involvement of at least 3% of body surface area (BSA); OR
    • Psoriasis Area and Severity Index (PASI) score of 10 or greater; OR
    • Incapacitation or serious emotional consequences due to plaque location (i.e., hands, feet, head and neck, genitalia, etc.) or with intractable pruritis; AND
  • Patient did not respond adequately (or is not a candidate) to a 4 week minimum trial of topical agents (i.e., anthralin, coal tar preparations, corticosteroids, emollients, immunosuppressives, keratolytics,, tapinarof, roflumilast, retinoic acid derivatives, and/or vitamin D analogues); AND
  • Patient did not respond adequately (or is not a candidate) to a 3 month minimum trial of at least one non-biologic systemic agent (i.e., immunosuppressives, retinoic acid derivatives, and/or methotrexate); AND
  • Patient did not respond adequately (or is not a candidate**) to a 3 month minimum trial of phototherapy (i.e., psoralens with UVA light [PUVA] or UVB with coal tar or dithranol)

Uveitis Associated with Behçet’s Syndrome ‡ 8-10,21,22,34,35, 93

  • Physician has assessed baseline disease severity utilizing an objective measure/tool; AND
  • Patient’s disease is refractory to immunosuppressive therapy (e.g., corticosteroids, cyclosporine, azathioprine, etc.); AND
  • Patient had an inadequate response to a self-administered biologic therapy (e.g., adalimumab)

Graft Versus Host Disease (GVHD) 43,65,66

  • Patient has received a hematopoietic stem cell transplant; AND
  • Used for steroid-refractory acute GVHD; AND
  • Used in combination with systemic corticosteroids as additional therapy following no response to first-line therapies

Management of Immune Checkpoint Inhibitor Related Toxicity 36,37,43,86

  • Patient has been receiving therapy with an immune checkpoint inhibitor (e.g., nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, cemiplimab, ipilimumab, dostarlimab, tremelimumab, retifanlimab, etc.); AND
  • Patient has one of the following toxicities related to their immunotherapy:
                • Myocarditis if no improvement within 24-48 hours of starting high-dose methylprednisolone; OR
                • Mild (G1) diarrhea or colitis if persistent or progressive symptoms and positive lactoferrin/calprotectin; OR
                • Moderate (G2) to severe (G3-4) diarrhea or colitis; OR
                • Moderate (G 2) pneumonitis if no improvement after 48-72 hours of corticosteroids; OR
                • Severe (G3-4) pneumonitis if no improvement after 48 hours of methylprednisolone; OR
                • Stage 3 acute kidney injury/elevated serum creatinine if toxicity remains >grade 2 after 4-6 weeks of corticosteroids or if creatinine increases during or after steroid taper; OR
                • Uveitis (G1-4) that is refractory to high-dose systemic corticosteroids; OR
                • Moderate to severe inflammatory arthritis; AND
      • Used as additional disease-modifying antirheumatic drug (DMARD) therapy; AND
      • Patient’s symptoms have not improved after holding immunotherapy AND one of the following:
          • Patient has not responded to oral corticosteroids; OR
          • Patient is unable to taper corticosteroids; OR
          • Patient has not had response to conventional synthetic (cs) DMARDs (i.e., methotrexate, hydroxychloroquine, leflunomide, or sulfasalazine)

**Examples of contraindications to phototherapy (PUVA or UVB) include the following: 67,68

  • Xeroderma pigmentosum
  • Other rare photosensitive genodermatoses (e.g., trichothiodystrophy, Cockayne syndrome, Bloom syndrome, Rothmund-Thomson syndrome) (UBV only)
  • Genetic disorders associated with increased risk of skin cancer (e.g., Gorlin syndrome, oculocutaneous albinism) (UVB only)
  • Pregnancy or lactation (PUVA only)
  • Lupus Erythematosus
  • History of one of the following: photosensitivity diseases (e.g., chronic actinic dermatitis, solar urticaria), melanoma, non-melanoma skin cancer, extensive solar damage (PUVA only), treatment with arsenic or ionizing radiation
  • Immunosuppression in an organ transplant patient (UVB only)
  • Photosensitizing medications (PUVA only)
  • Severe liver, renal, or cardiac disease (PUVA only)
  • Young age < 12 years old (PUVA only)

FDA Approved Indication(s); Compendia Recommended Indication(s); Ф Orphan Drug

  1. Renewal Criteria 1-4

Coverage can be renewed based upon the following criteria:

For PEEHIP Members Only

  • Inflectra and Renflexis are the preferred infliximab products. Patients currently on Remicade, Infliximab*, or Avsola may complete their current course of treatment for the duration of the current precertification period; upon precertification renewal or restarting therapy, transition to a preferred product is required. Remicade, Infliximab*, and Avsola are non-covered for new to therapy members and will be non-covered for patients after their current precertification expires. *Unbranded product.

For Commercial Members Only

  • Remicade, Infliximab*, Inflectra and Avsola are the preferred infliximab products.  Patients must have failed, or have a contraindication, or intolerance to at least two of the preferred infliximab products prior to consideration of Renflexis. Patients who have been receiving Renflexis may continue therapy with that product.

*unbranded biologic

  • Patient continues to meet the universal and other indication-specific relevant criteria identified in section III; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: severe hypersensitivity reactions, malignancy (e.g., lymphoma including hepatosplenic T-cell lymphoma, skin cancers, cervical cancer, etc.), significant hematologic abnormalities (e.g., leukopenia, neutropenia, thrombocytopenia, pancytopenia), serious infections (e.g., TB, serious fungal infections, HBV reactivation, etc.), cardiovascular and cerebrovascular accidents, heart failure, neurotoxicity/ demyelinating disorders, hepatotoxicity, lupus-like syndrome, etc.; AND

Crohn’s Disease 23

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as endoscopic activity, number of liquid stools, presence and severity of abdominal pain, presence of abdominal mass, body weight compared to IBW, hematocrit, presence of extra-intestinal complications, tapering or discontinuation of corticosteroid therapy, use of anti-diarrheal drugs, and/or an improvement on a disease activity scoring tool [e.g. an improvement on the Crohn’s Disease Activity Index (CDAI) score or the Harvey-Bradshaw Index score].

Pediatric Crohn’s Disease 23

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as endoscopic activity, number of liquid stools, presence and severity of abdominal pain, presence of abdominal mass, body weight compared to IBW, hematocrit, presence of extra-intestinal complications, tapering or discontinuation of corticosteroid therapy, use of anti-diarrheal drugs and/or an improvement on a disease activity scoring tool [e.g. an improvement on the Pediatric Crohn’s Disease Activity Index (PCDAI) score or the Harvey-Bradshaw Index score].

Ulcerative Colitis 24-27

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as stool frequency, rectal bleeding, and/or endoscopic activity, tapering or discontinuation of corticosteroid therapy, and/or an improvement on a disease activity scoring tool [e.g. an improvement on the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score or the Mayo Score].

Pediatric Ulcerative Colitis 24-26

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as stool frequency, rectal bleeding, and/or endoscopic activity, tapering or discontinuation of corticosteroid therapy, and/or an improvement on a disease activity scoring tool [e.g. an improvement on the Pediatric Ulcerative Colitis Activity Index (PUCAI) score or the Mayo Score].

Fistulizing Crohn’s Disease 23

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as a reduction in number of enterocutaneous fistulas draining upon gentle compression, and/or an improvement on a disease activity scoring tool [e.g. an improvement on the Crohn’s Disease Activity Index (CDAI) score or the Harvey-Bradshaw Index score].

Psoriatic Arthritis 28,72

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts and/or an improvement on a disease activity scoring tool [e.g. defined as an improvement in at least 2 of the 4 Psoriatic Arthritis Response Criteria (PsARC), 1 of which must be joint tenderness or swelling score, with no worsening in any of the 4 criteria].

Rheumatoid Arthritis 29-31, 91

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts, reduction of C-reactive protein, improvement of patient global assessment, and/or an improvement on a disease activity scoring tool [e.g. an improvement on a composite scoring index such as Disease Activity Score-28 (DAS28) of 1.2 points or more or a ≥20% improvement on the American College of Rheumatology-20 (ACR20) criteria].

Ankylosing Spondylitis 19,87

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as total back pain, physical function, morning stiffness, and/or an improvement on a disease activity scoring tool [e.g. ≥ 1.1 improvement on the Ankylosing Spondylitis Disease Activity Score (ASDAS) or an improvement of ≥ 2 on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)].

Plaque Psoriasis (PsO) 33,69,79,88,90

  • Disease response as indicated by improvement in signs and symptoms compared to baseline such as redness, thickness, scaliness, and/or the amount of surface area involvement (a total BSA involvement ≤1%), and/or an improvement on a disease activity scoring tool [e.g. a 75% reduction in the PASI score from when treatment started (PASI 75) or a 50% reduction in the PASI score (PASI 50) and a four-point reduction in the DLQI from when treatment started].

Uveitis Associated with Behçet’s Syndrome 34-35

  • Disease response as indicated by an improvement in signs and symptoms compared to baseline [e.g. reduction in inflammation and/or lesions, dose reduction of oral glucocorticoids and/or immunosuppressive agents, improvement in vitreous haze, improvement in best corrected visual acuity (BCVA), disease stability and/or reduced rate of decline].

Acute GVHD ‡ 65,66

  • May not be renewed (Note: Requests for continued therapy beyond four doses will be reviewed on a case-by-case basis.)

Management of Immune Checkpoint Inhibitor related Toxicity ‡ 86

  • May not be renewed.
  1. Dosage/Administration 1-4,36,37,42,66,86

Indication

Loading Doses

Maintenance Dosing

Maximum Dose & Frequency

Rheumatoid Arthritis

3 mg/kg at weeks 0, 2, & 6

3 mg/kg every 8 weeks thereafter

Up to 10 mg/kg every 4 weeks

Ankylosing Spondylitis

5 mg/kg at weeks 0, 2, & 6

5 mg/kg every 6 weeks thereafter

5 mg/kg every 6 weeks

Crohn’s Disease & Ulcerative Colitis

5 mg/kg at weeks 0, 2, & 6

5 mg/kg every 8 weeks thereafter

Up to 10 mg/kg every 8 weeks

Psoriatic Arthritis, Plaque Psoriasis, Behçet’s Uveitis

5 mg/kg at weeks 0, 2, & 6

5 mg/kg every 8 weeks thereafter

5 mg/kg every 8 weeks

Management of Immune Checkpoint Inhibitor Related Toxicity

5 mg/kg at weeks 0,2

N/A

N/A

Acute GVHD

10 mg/kg at week 0,1,2 & 3

N/A

N/A

  • Dose escalation (up to the maximum dose and frequency specified above) may occur upon clinical review on a case by case basis provided that the patient has:
    • Shown an initial response to therapy; AND
    • Received the three loading doses at the dose AND interval specified above; AND
    • Received a minimum of one maintenance dose at the dose AND interval specified above; AND
    • Responded to therapy (by treatment week 16) with subsequent loss of response; AND
    • Dose escalation may either increase the dose OR decrease the interval provided it does not exceed the following limits:
      • Dose increase by no more than 2.5 mg/kg; OR
      • Interval decrease by no more than 2 weeks

Note:

  • Prior to escalating doses a patient's neutralizing IFX-antibodies should be assessed and addition of a DMARD (e.g., thiopurine or MTX), if not already on such therapy, should be considered.
  • Criteria for disease-specific response to therapy are noted in section IV. Patients with moderate to severe heart failure (NYHA Functional Class III/IV; LVEF ≤35%) should not receive doses in excess of 5 mg/kg.
  1. Billing Code/Availability Information

HCPCS Code:

  • J1745 – Injection, infliximab, excludes biosimilar, 10 mg; 1 billable unit = 10 mg (Includes unbranded biologic)
  • Q5103 – Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg: 1 billable unit = 10 mg
  • Q5104 – Injection, infliximab-abda, biosimilar, (renflexis), 10 mg; 1 billable unit = 10 mg
  • Q5121 – Injection, infliximab-axxq, biosimilar, (avsola), 10 mg: 1 billable unit=10 mg

NDC:

  • Remicade 100 mg single-dose vial for injection: 57894-0030-xx
  • Infliximab 100 mg single-dose vial for injection: 57894-0160-xx (Unbranded biologic*)
  • Inflectra 100 mg single-dose vial: 00069-0809-xx
  • Renflexis 100 mg single-dose vial: 78206-0162-xx
  • Avsola 100 mg single-dose vial for injection: 55513-0670-xx

*An unbranded biologic is the same as the brand biologic, Remicade, using the same cell-line as the brand-name reference biologic.

  1. References
  1. Remicade/Infliximab [package insert]. Horsham, PA; Janssen Biotech, Inc; October 2021. Accessed September 2023.
  2. Inflectra [package insert]. Yeonsu-gu, Incheon, Republic of Korea; CELLTRION, Inc; April 2023. Accessed September 2023.
  3. Renflexis [package insert]. Yeonsu-gu, Incheon, Republic of Korea; Samsung Bioepis Co., Ltd; January 2022. Accessed September 2023.
  4. Avsola [package insert]. Thousand Oaks, CA; Amgen, Inc; September 2021. Accessed September 2023.
  5. Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2015 Nov 6. doi: 10.1002/acr.22783.
  6. Ward MM, Deodhar, A, Akl, EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2015 Sep 24. doi: 10.1002/art.39298.
  7. Menter A, Feldman SR, Weinstein GD, et al. A randomized comparison of continuous vs. intermittent infliximab maintenance regimens over 1 year in the treatment of moderate-to-severe plaque psoriasis. J Am Acad Dermatol 2007;56:31e1-15.
  8. Niccoli L, Nannini C, Benucci M, et al. Long-term efficacy of infliximab in refractory posterior uveitis of Behcet’s disease: a 24-month follow-up study. Rheumatology (Oxford). 2007 Jul;46(7):1161-4. Epub 2007 May 3.
  9. Giardina A, Ferrante A, Ciccia F, et al. One year study of efficacy and safety of infliximab in the treatment of patients with ocular and neurological Behcet’s disease refractory to standard immunosuppressive drugs. Rheumatol Int 2011;31:33–37.
  10. Okada A, Goto H, Ohno S, et al. Multicenter study of infliximab for refractory uveoretinitis in Behcet disease. Arch Ophthalmol 2012;130(5):592-598.
  11. Lichtenstein GR, Loftus EV, Isaacs KL, et al. American College of Gastroenterology. Clinical Guideline: Management of Crohn’s disease in adults. Am J Gastroenterol. 2018;113:481-517.
  12. Kornbluth, A, Sachar, DB; Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010 Mar;105(3):501-23.
  13. Terdiman JP, Gruss CB, Heidelbaugh JJ, et al. American Gastroenterological Association Institute guideline on the use of thiopurines, methotrexate, and anti-TNF-α biologic drugs for the induction and maintenance of remission in inflammatory Crohn's disease. Gastroenterology. 2013 Dec;145(6):1459-63. doi: 10.1053/j.gastro.2013.10.047.
  14. Hsu S, Papp KA, Lebwohl MG, et al. Consensus guidelines for the management of plaque psoriasis. Arch Dermatol. 2012 Jan;148(1):95-102.
  15. Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JY, Van Voorhees AS, Elmets CA, Leonardi CL, Beutner KR, Bhushan R, Menter A. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol 2008 May;58(5):851-64.
  16. National Institute for Health and Clinical Excellence (NICE). Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Aug. 73 p. (Technology appraisal guidance; no. 195)
  17. Gossec L, Smolen JS, Ramiro S, et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. 2015 Dec 7. pii: annrheumdis-2015-208337. doi: 10.1136/annrheumdis-2015-208337.
  18. Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Mar 6. pii: annrheumdis-2016-210715.
  19. Van Der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis.  Ann Rheum Dis doi:10.1136/annrheumdis-2016-210770.
  20. Harbord M, Eliakim R, Bettenworth D, et al. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 2: Current Management. J Crohns Colitis. 2017 Jan 28. doi: 10.1093/ecco-jcc/jjx009.
  21. Jabs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol. 2000 Oct;130(4):492-513.
  22. Levy-Clarke G, Jabs DA, Read RW, et al. Expert panel recommendations for the use of anti-tumor necrosis factor biologic agents in patients with ocular inflammatory disorders. Ophthalmology. 2014 Mar;121(3):785-96.e3. doi: 10.1016/j.ophtha.2013.09.048.
  23. National Institute for Health and Care Excellence. NICE 2019. Crohn’s disease: management. Published 03 May 2019. NICE guideline [NG129]. https://www.nice.org.uk/guidance/ng129. Accessed September 2023.
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  56. Yoo DH, Prodanovic N, Jaworski J, et al. Efficacy and safety of CT-P13 (biosimilar infliximab) in patients with rheumatoid arthritis: comparison between switching from reference infliximab to CT-P13 and continuing CT-P13 in the PLANETRA extension study. Ann Rheum Dis. 2017 Feb;76(2):355-363.
  57. Park W, Yoo DH, Miranda P, et al. Efficacy and safety of switching from reference infliximab to CT-P13 compared with maintenance of CT-P13 in ankylosing spondylitis: 102-week data from the PLANETAS extension study. Ann Rheum Dis. 2017 Feb;76(2):346-354.
  58. Goll GL, Jørgensen KK, Sexton J, et al. Long-term efficacy and safety of biosimilar infliximab (CT-P13) after switching from originator infliximab: open-label extension of the NOR-SWITCH trial. J Intern Med. 2019 Jun;285(6):653-669.
  59. Choe JY, Prodanovic N, Niebrzydowski J, et al. A randomised, double-blind, phase III study comparing SB2, an infliximab biosimilar, to the infliximab reference product Remicade in patients with moderate to severe rheumatoid arthritis despite methotrexate therapy. Ann Rheum Dis. 2017 Jan;76(1):58-64.
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  62. Smolen JS, Choe JY, Prodanovic N, Niebrzydowski J, Staykov I, Dokoupilova E, et al. Safety, immunogenicity and efficacy after switching from reference infliximab to biosimilar SB2 compared with continuing reference infliximab and SB2 in patients with rheumatoid arthritis: results of a randomised, double-blind, phase III transition study. Ann Rheum Dis 2017. E-pub ahead of print.
  63. Chow V, Oh M, Gessner M, Fanjiang G. Pharmacokinetic similarity of ABP 710, a proposed biosimilar to infliximab: results from a randomized, singleblind, singledose, parallelgroup study in healthy subjects. Clin Pharmacol Drug Dev. 2019. doi:10.1002/cpdd.738
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  68. Smith CH, Yiu ZZN, Bale T, et al; British Association of Dermatologists’ Clinical Standards Unit. British Association of Dermatologists guidelines for biologic therapy for psoriasis 2020: a rapid update. Br J Dermatol. 2020 Oct;183(4):628-637. doi: 10.1111/bjd.19039.
  69. Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020 Jan;82(1):161-201. doi: 10.1016/j.jaad.2019.08.049.
  70. Gossec L, Baraliakos X, Kerschbaumer A, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020 Jun;79(6):700-712. doi: 10.1136/annrheumdis-2020-217159.
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Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

D89.810

Acute graft-versus host disease

D89.812

Acute on chronic graft-versus-host-disease

D89.813

Graft-versus-host disease unspecified

H30.891

Other chorioretinal inflammations, right eye

H30.892

Other chorioretinal inflammations, left eye

H30.893

Other chorioretinal inflammations, bilateral

H30.899

Other chorioretinal inflammations, unspecified eye

H30.90

Unspecified chorioretinal inflammation, unspecified eye

H30.91

Unspecified chorioretinal inflammation, right eye

H30.92

Unspecified chorioretinal inflammation, left eye

H30.93

Unspecified chorioretinal inflammation, bilateral

H44.111

Panuveitis, right eye

H44.112

Panuveitis, left eye

H44.113

Panuveitis, bilateral

H44.119

Panuveitis, unspecified eye

I30.8

Other forms of acute pericarditis

I30.9

Acute pericarditis, unspecified

I40.8

Other acute myocarditis

I40.9

Acute myocarditis, unspecified

J70.2

Acute drug-induced interstitial lung disorders

J70.4

Drug-induced interstitial lung disorders, unspecified

K50.00

Crohn’s disease of small intestine without complications

K50.011

Crohn’s disease of small intestine with rectal bleeding

K50.012

Crohn’s disease of small intestine with intestinal obstruction

K50.013

Crohn’s disease of small intestine with fistula

K50.014

Crohn’s disease of small intestine with abscess

K50.018

Crohn’s disease of small intestine with other complication

K50.019

Crohn’s disease of small intestine with unspecified complications

K50.10

Crohn’s disease of large intestine without complications

K50.111

Crohn’s disease of large intestine with rectal bleeding

K50.112

Crohn’s disease of large intestine with intestinal obstruction

K50.113

Crohn’s disease of large intestine with fistula

K50.114

Crohn’s disease of large intestine with abscess

K50.118

Crohn’s disease of large intestine with other complication

K50.119

Crohn’s disease of large intestine with unspecified complications

K50.80

Crohn’s disease of both small and large intestine without complications

K50.811

Crohn’s disease of both small and large intestine with rectal bleeding

K50.812

Crohn’s disease of both small and large intestine with intestinal obstruction

K50.813

Crohn’s disease of both small and large intestine with fistula

K50.814

Crohn’s disease of both small and large intestine with abscess

K50.818

Crohn’s disease of both small and large intestine with other complication

K50.819

Crohn’s disease of both small and large intestine with unspecified complications

K50.90

Crohn’s disease, unspecified, without complications

K50.911

Crohn’s disease, unspecified, with rectal bleeding

K50.912

Crohn’s disease, unspecified, with intestinal obstruction

K50.913

Crohn’s disease, unspecified, with fistula

K50.914

Crohn’s disease, unspecified, with abscess

K50.918

Crohn’s disease, unspecified, with other complication

K50.919

Crohn’s disease, unspecified, with unspecified complications

K51.00

Ulcerative (chronic) pancolitis without complications

K51.011

Ulcerative (chronic) pancolitis with rectal bleeding

K51.012

Ulcerative (chronic) pancolitis with intestinal obstruction

K51.013

Ulcerative (chronic) pancolitis with fistula

K51.014

Ulcerative (chronic) pancolitis with abscess

K51.018

Ulcerative (chronic) pancolitis with other complication

K51.019

Ulcerative (chronic) pancolitis with unspecified complications

K51.20

Ulcerative (chronic) proctitis without complications

K51.211

Ulcerative (chronic) proctitis with rectal bleeding

K51.212

Ulcerative (chronic) proctitis with intestinal obstruction

K51.213

Ulcerative (chronic) proctitis with fistula

K51.214

Ulcerative (chronic) proctitis with abscess

K51.218

Ulcerative (chronic) proctitis with other complication

K51.219

Ulcerative (chronic) proctitis with unspecified complications

K51.30

Ulcerative (chronic) rectosigmoiditis without complications

K51.311

Ulcerative (chronic) rectosigmoiditis with rectal bleeding

K51.312

Ulcerative (chronic) rectosigmoiditis with intestinal obstruction

K51.313

Ulcerative (chronic) rectosigmoiditis with fistula

K51.314

Ulcerative (chronic) rectosigmoiditis with abscess

K51.318

Ulcerative (chronic) rectosigmoiditis with other complication

K51.319

Ulcerative (chronic) rectosigmoiditis with unspecified complications

K51.50

Left sided colitis without complications

K51.511

Left sided colitis with rectal bleeding

K51.512

Left sided colitis with intestinal obstruction

K51.513

Left sided colitis with fistula

K51.514

Left sided colitis with abscess

K51.518

Left sided colitis with other complication

K51.519

Left sided colitis with unspecified complications

K51.80

Other ulcerative colitis without complications

K51.811

Other ulcerative colitis with rectal bleeding

K51.812

Other ulcerative colitis with intestinal obstruction

K51.813

Other ulcerative colitis with fistula

K51.814

Other ulcerative colitis with abscess

K51.818

Other ulcerative colitis with other complication

K51.819

Other ulcerative colitis with unspecified complications

K51.90

Ulcerative colitis, unspecified, without complications

K51.911

Ulcerative colitis, unspecified with rectal bleeding

K51.912

Ulcerative colitis, unspecified with intestinal obstruction

K51.913

Ulcerative colitis, unspecified with fistula

K51.914

Ulcerative colitis, unspecified with abscess

K51.918

Ulcerative colitis, unspecified with other complication

K51.919

Ulcerative colitis, unspecified with unspecified complications

K52.1

Toxic gastroenteritis and colitis

L40.0

Psoriasis vulgaris

L40.50

Arthropathic psoriasis, unspecified

L40.51

Distal interphalangeal psoriatic arthropathy

L40.52

Psoriatic arthritis mutilans

L40.53

Psoriatic spondylitis

L40.59

Other psoriatic arthropathy

M05.10

Rheumatoid lung disease with rheumatoid arthritis of unspecified site

M05.111

Rheumatoid lung disease with rheumatoid arthritis of right shoulder

M05.112

Rheumatoid lung disease with rheumatoid arthritis of left shoulder

M05.119

Rheumatoid lung disease with rheumatoid arthritis of unspecified shoulder

M05.121

Rheumatoid lung disease with rheumatoid arthritis of right elbow

M05.122

Rheumatoid lung disease with rheumatoid arthritis of left elbow

M05.129

Rheumatoid lung disease with rheumatoid arthritis of unspecified elbow

M05.131

Rheumatoid lung disease with rheumatoid arthritis of right wrist

M05.132

Rheumatoid lung disease with rheumatoid arthritis of left wrist

M05.139

Rheumatoid lung disease with rheumatoid arthritis of unspecified wrist

M05.141

Rheumatoid lung disease with rheumatoid arthritis of right hand

M05.142

Rheumatoid lung disease with rheumatoid arthritis of left hand

M05.149

Rheumatoid lung disease with rheumatoid arthritis of unspecified hand

M05.151

Rheumatoid lung disease with rheumatoid arthritis of right hip

M05.152

Rheumatoid lung disease with rheumatoid arthritis of left hip

M05.159

Rheumatoid lung disease with rheumatoid arthritis of unspecified hip

M05.161

Rheumatoid lung disease with rheumatoid arthritis of right knee

M05.162

Rheumatoid lung disease with rheumatoid arthritis of left knee

M05.169

Rheumatoid lung disease with rheumatoid arthritis of unspecified knee

M05.171

Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot

M05.172

Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot

M05.179

Rheumatoid lung disease with rheumatoid arthritis of unspecified ankle and foot

M05.19

Rheumatoid lung disease with rheumatoid arthritis of multiple sites

M05.20

Rheumatoid vasculitis with rheumatoid arthritis of unspecified site

M05.211

Rheumatoid vasculitis with rheumatoid arthritis of right shoulder

M05.212

Rheumatoid vasculitis with rheumatoid arthritis of left shoulder

M05.219

Rheumatoid vasculitis with rheumatoid arthritis of unspecified shoulder

M05.221

Rheumatoid vasculitis with rheumatoid arthritis of right elbow

M05.222

Rheumatoid vasculitis with rheumatoid arthritis of left elbow

M05.229

Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow

M05.231

Rheumatoid vasculitis with rheumatoid arthritis of right wrist

M05.232

Rheumatoid vasculitis with rheumatoid arthritis of left wrist

M05.239

Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist

M05.241

Rheumatoid vasculitis with rheumatoid arthritis of right hand

M05.242

Rheumatoid vasculitis with rheumatoid arthritis of left hand

M05.249

Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand

M05.251

Rheumatoid vasculitis with rheumatoid arthritis of right hip

M05.252

Rheumatoid vasculitis with rheumatoid arthritis of left hip

M05.259

Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip

M05.261

Rheumatoid vasculitis with rheumatoid arthritis of right knee

M05.262

Rheumatoid vasculitis with rheumatoid arthritis of left knee

M05.269

Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee

M05.271

Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot

M05.272

Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot

M05.279

Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot

M05.29

Rheumatoid vasculitis with rheumatoid arthritis of multiple sites

M05.30

Rheumatoid heart disease with rheumatoid arthritis of unspecified site

M05.311

Rheumatoid heart disease with rheumatoid arthritis of right shoulder

M05.312

Rheumatoid heart disease with rheumatoid arthritis of left shoulder

M05.319

Rheumatoid heart disease with rheumatoid arthritis of unspecified shoulder

M05.321

Rheumatoid heart disease with rheumatoid arthritis of right elbow

M05.322

Rheumatoid heart disease with rheumatoid arthritis of left elbow

M05.329

Rheumatoid heart disease with rheumatoid arthritis of unspecified elbow

M05.331

Rheumatoid heart disease with rheumatoid arthritis of right wrist

M05.332

Rheumatoid heart disease with rheumatoid arthritis of left wrist

M05.339

Rheumatoid heart disease with rheumatoid arthritis of unspecified wrist

M05.341

Rheumatoid heart disease with rheumatoid arthritis of right hand

M05.342

Rheumatoid heart disease with rheumatoid arthritis of left hand

M05.349

Rheumatoid heart disease with rheumatoid arthritis of unspecified hand

M05.351

Rheumatoid heart disease with rheumatoid arthritis of right hip

M05.352

Rheumatoid heart disease with rheumatoid arthritis of left hip

M05.359

Rheumatoid heart disease with rheumatoid arthritis of unspecified hip

M05.361

Rheumatoid heart disease with rheumatoid arthritis of right knee

M05.362

Rheumatoid heart disease with rheumatoid arthritis of left knee

M05.369

Rheumatoid heart disease with rheumatoid arthritis of unspecified knee

M05.371

Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot

M05.372

Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot

M05.379

Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot

M05.39

Rheumatoid heart disease with rheumatoid arthritis of multiple sites

M05.40

Rheumatoid myopathy with rheumatoid arthritis of unspecified site

M05.411

Rheumatoid myopathy with rheumatoid arthritis of right shoulder

M05.412

Rheumatoid myopathy with rheumatoid arthritis of left shoulder

M05.419

Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder

M05.421

Rheumatoid myopathy with rheumatoid arthritis of right elbow

M05.422

Rheumatoid myopathy with rheumatoid arthritis of left elbow

M05.429

Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow

M05.431

Rheumatoid myopathy with rheumatoid arthritis of right wrist

M05.432

Rheumatoid myopathy with rheumatoid arthritis of left wrist

M05.439

Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist

M05.441

Rheumatoid myopathy with rheumatoid arthritis of right hand

M05.442

Rheumatoid myopathy with rheumatoid arthritis of left hand

M05.449

Rheumatoid myopathy with rheumatoid arthritis of unspecified hand

M05.451

Rheumatoid myopathy with rheumatoid arthritis of right hip

M05.452

Rheumatoid myopathy with rheumatoid arthritis of left hip

M05.459

Rheumatoid myopathy with rheumatoid arthritis of unspecified hip

M05.461

Rheumatoid myopathy with rheumatoid arthritis of right knee

M05.462

Rheumatoid myopathy with rheumatoid arthritis of left knee

M05.469

Rheumatoid myopathy with rheumatoid arthritis of unspecified knee

M05.471

Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot

M05.472

Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot

M05.479

Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot

M05.49

Rheumatoid myopathy with rheumatoid arthritis of multiple sites

M05.50

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site

M05.511

Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder

M05.512

Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder

M05.519

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder

M05.521

Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow

M05.522

Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow

M05.529

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow

M05.531

Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist

M05.532

Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist

M05.539

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist

M05.541

Rheumatoid polyneuropathy with rheumatoid arthritis of right hand

M05.542

Rheumatoid polyneuropathy with rheumatoid arthritis of left hand

M05.549

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand

M05.551

Rheumatoid polyneuropathy with rheumatoid arthritis of right hip

M05.552

Rheumatoid polyneuropathy with rheumatoid arthritis of left hip

M05.559

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip

M05.561

Rheumatoid polyneuropathy with rheumatoid arthritis of right knee

M05.562

Rheumatoid polyneuropathy with rheumatoid arthritis of left knee

M05.569

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee

M05.571

Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot

M05.572

Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot

M05.579

Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot

M05.59

Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites

M05.60

Rheumatoid arthritis of unspecified site with involvement of other organs and systems

M05.611

Rheumatoid arthritis of right shoulder with involvement of other organs and systems

M05.612

Rheumatoid arthritis of left shoulder with involvement of other organs and systems

M05.619

Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems

M05.621

Rheumatoid arthritis of right elbow with involvement of other organs and systems

M05.622

Rheumatoid arthritis of left elbow with involvement of other organs and systems

M05.629

Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems

M05.631

Rheumatoid arthritis of right wrist with involvement of other organs and systems

M05.632

Rheumatoid arthritis of left wrist with involvement of other organs and systems

M05.639

Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems

M05.641

Rheumatoid arthritis of right hand with involvement of other organs and systems

M05.642

Rheumatoid arthritis of left hand with involvement of other organs and systems

M05.649

Rheumatoid arthritis of unspecified hand with involvement of other organs and systems

M05.651

Rheumatoid arthritis of right hip with involvement of other organs and systems

M05.652

Rheumatoid arthritis of left hip with involvement of other organs and systems

M05.659

Rheumatoid arthritis of unspecified hip with involvement of other organs and systems

M05.661

Rheumatoid arthritis of right knee with involvement of other organs and systems

M05.662

Rheumatoid arthritis of left knee with involvement of other organs and systems

M05.669

Rheumatoid arthritis of unspecified knee with involvement of other organs and systems

M05.671

Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems

M05.672

Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems

M05.679

Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems

M05.69

Rheumatoid arthritis of multiple sites with involvement of other organs and systems

M05.7A

Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement

M05.711

Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement

M05.712

Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement

M05.719

Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement

M05.721

Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement

M05.722

Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement

M05.729

Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement

M05.731

Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement

M05.732

Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement

M05.739

Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement

M05.741

Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement

M05.742

Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement

M05.749

Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement

M05.751

Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement

M05.752

Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement

M05.759

Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement

M05.761

Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement

M05.762

Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement

M05.769

Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement

M05.771

Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement

M05.772

Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement

M05.779

Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement

M05.79

Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement

M05.8A

Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement

M05.811

Other rheumatoid arthritis with rheumatoid factor of right shoulder

M05.812

Other rheumatoid arthritis with rheumatoid factor of left shoulder

M05.819

Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder

M05.821

Other rheumatoid arthritis with rheumatoid factor of right elbow

M05.822

Other rheumatoid arthritis with rheumatoid factor of left elbow

M05.829

Other rheumatoid arthritis with rheumatoid factor of unspecified elbow

M05.831

Other rheumatoid arthritis with rheumatoid factor of right wrist

M05.832

Other rheumatoid arthritis with rheumatoid factor of left wrist

M05.839

Other rheumatoid arthritis with rheumatoid factor of unspecified wrist

M05.841

Other rheumatoid arthritis with rheumatoid factor of right hand

M05.842

Other rheumatoid arthritis with rheumatoid factor of left hand

M05.849

Other rheumatoid arthritis with rheumatoid factor of unspecified hand

M05.851

Other rheumatoid arthritis with rheumatoid factor of right hip

M05.852

Other rheumatoid arthritis with rheumatoid factor of left hip

M05.859

Other rheumatoid arthritis with rheumatoid factor of unspecified hip

M05.861

Other rheumatoid arthritis with rheumatoid factor of right knee

M05.862

Other rheumatoid arthritis with rheumatoid factor of left knee

M05.869

Other rheumatoid arthritis with rheumatoid factor of unspecified knee

M05.871

Other rheumatoid arthritis with rheumatoid factor of right ankle and foot

M05.872

Other rheumatoid arthritis with rheumatoid factor of left ankle and foot

M05.879

Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot

M05.89

Other rheumatoid arthritis with rheumatoid factor of multiple sites

M05.9

Rheumatoid arthritis with rheumatoid factor, unspecified

M06.0A

Rheumatoid arthritis without rheumatoid factor, other specified site

M06.011

Rheumatoid arthritis without rheumatoid factor, right shoulder

M06.012

Rheumatoid arthritis without rheumatoid factor, left shoulder

M06.019

Rheumatoid arthritis without rheumatoid factor, unspecified shoulder

M06.021

Rheumatoid arthritis without rheumatoid factor, right elbow

M06.022

Rheumatoid arthritis without rheumatoid factor, left elbow

M06.029

Rheumatoid arthritis without rheumatoid factor, unspecified elbow

M06.031

Rheumatoid arthritis without rheumatoid factor, right wrist

M06.032

Rheumatoid arthritis without rheumatoid factor, left wrist

M06.039

Rheumatoid arthritis without rheumatoid factor, unspecified wrist

M06.041

Rheumatoid arthritis without rheumatoid factor, right hand

M06.042

Rheumatoid arthritis without rheumatoid factor, left hand

M06.049

Rheumatoid arthritis without rheumatoid factor, unspecified hand

M06.051

Rheumatoid arthritis without rheumatoid factor, right hip

M06.052

Rheumatoid arthritis without rheumatoid factor, left hip

M06.059

Rheumatoid arthritis without rheumatoid factor, unspecified hip

M06.061

Rheumatoid arthritis without rheumatoid factor, right knee

M06.062

Rheumatoid arthritis without rheumatoid factor, left knee

M06.069

Rheumatoid arthritis without rheumatoid factor, unspecified knee

M06.071

Rheumatoid arthritis without rheumatoid factor, right ankle and foot

M06.072

Rheumatoid arthritis without rheumatoid factor, left ankle and foot

M06.079

Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot

M06.08

Rheumatoid arthritis without rheumatoid factor, vertebrae

M06.09

Rheumatoid arthritis without rheumatoid factor, multiple sites

M06.4

Inflammatory polyarthropathy

M06.8A

Other specified rheumatoid arthritis, other specified site

M06.811

Other specified rheumatoid arthritis, right shoulder

M06.812

Other specified rheumatoid arthritis, left shoulder

M06.819

Other specified rheumatoid arthritis, unspecified shoulder

M06.821

Other specified rheumatoid arthritis, right elbow

M06.822

Other specified rheumatoid arthritis, left elbow

M06.829

Other specified rheumatoid arthritis, unspecified elbow

M06.831

Other specified rheumatoid arthritis, right wrist

M06.832

Other specified rheumatoid arthritis, left wrist

M06.839

Other specified rheumatoid arthritis, unspecified wrist

M06.841

Other specified rheumatoid arthritis, right hand

M06.842

Other specified rheumatoid arthritis, left hand

M06.849

Other specified rheumatoid arthritis, unspecified hand

M06.851

Other specified rheumatoid arthritis, right hip

M06.852

Other specified rheumatoid arthritis, left hip

M06.859

Other specified rheumatoid arthritis, unspecified hip

M06.861

Other specified rheumatoid arthritis, right knee

M06.862

Other specified rheumatoid arthritis, left knee

M06.869

Other specified rheumatoid arthritis, unspecified knee

M06.871

Other specified rheumatoid arthritis, right ankle and foot

M06.872

Other specified rheumatoid arthritis, left ankle and foot

M06.879

Other specified rheumatoid arthritis, unspecified ankle and foot

M06.88

Other specified rheumatoid arthritis, vertebrae

M06.89

Other specified rheumatoid arthritis, multiple sites

M06.9

Rheumatoid arthritis, unspecified

M35.2

Behçet’s disease

M45.0

Ankylosing spondylitis of multiple sites in spine

M45.1

Ankylosing spondylitis of occipito-atlanto-axial region

M45.2

Ankylosing spondylitis of cervical region

M45.3

Ankylosing spondylitis of cervicothoracic region

M45.4

Ankylosing spondylitis of thoracic region

M45.5

Ankylosing spondylitis of thoracolumbar region

M45.6

Ankylosing spondylitis lumbar region

M45.7

Ankylosing spondylitis of lumbosacral region

M45.8

Ankylosing spondylitis sacral and sacrococcygeal region

M45.9

Ankylosing spondylitis of unspecified sites in spine

M79.10

Myalgia, unspecified

M79.11

Myalgia of mastication muscle

M79.12

Myalgia of auxiliary muscles, head and neck

M79.18

Myalgia, other site

N17.8

Other acute kidney failure

N17.9

Acute kidney failure, unspecified

R19.7

Diarrhea, unspecified

T86.09

Other complications of bone marrow transplant

Z94.81

Bone marrow transplant status

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA):

Jurisdiction(s): J,M

NCD/LCD/LCA Document (s): A56432

https://www.cms.gov/medicare-coverage-database/new-search/search-results.aspx?keyword=a56432&areaId=all&docType=NCA%2CCAL%2CNCD%2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP

Jurisdiction(s): 6,K

NCD/LCD/LCA Document (s): A52423

https://www.cms.gov/medicare-coverage-database/new-search/search-results.aspx?keyword=a52423&areaId=all&docType=NCA%2CCAL%2CNCD%2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP  

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC

 

 

 

 

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