Payer PolicyActive
Infliximab (Remicade, Inflectra, Renflexis, Avsola)
EVICORE-MEDICAL_DRUG-BDA99750
EviCore by Evernorth
Effective: February 1, 2021
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered: infliximab products (Remicade, Inflectra, Renflexis, Avsola) for specified FDA‑approved non‑oncology indications and approved off‑label compendial uses (oncology indications excluded). Key requirements: indication‑specific prior‑therapy trials, age limits, and specialist prescription/consultation with documented diagnosis, prior treatments and durations, weight‑based dosing and infusion records (infusions ≥2 hours), documented clinical response for reauthorization, and adherence to specified initial and renewal approval durations.
Coverage Criteria Preview
Key requirements from the full policy
"Approved Off-label Compendial Uses: Juvenile idiopathic arthritis"
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