Remicade and Orencia: New Claims Edits Effective in June

  • March 7, 2019

    On June 9, 2019, there will be new claims edits for drugs administered in the provider office:

    • Remicade (infliximab)
    • Inflectra (infliximab-dyyb)
    • Renflexis (infliximab-abda)
    • Orencia (abatacept)

    The edits apply age restrictions, dose, and dose frequency limits consistent with Food and Drug Administration (FDA) prescribing information.

    Because neutralizing antibodies results in increased infusion needs for some patients and scheduling patients on the precise day their next dose is due may cause difficulties for patients, the plan is allowing specific grace periods:

    Remicade, Inflectra, and Renflexis

    • Age restriction 6 years of age and older for pediatric Crohn’s disease and pediatric ulcerative colitis
    • Dose frequency limits based on the FDA prescribing information, with specific grace periods:
      1. Induction treatment (for all indications which are Crohn’s disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis)
        a. For week 2 (day 14) infusion, up to a 7-day early infusion is allowed
        b. For week 6 (day 42) infusion, up to a 7-day early infusion is allowed
      2. Maintenance treatment
        a. For ankylosing spondylitis administered every 6 weeks, up to a 10-day early infusion is allowed
        b. For Crohn’s disease, ulcerative colitis, psoriatic arthritis and plaque psoriasis administered every 8 weeks, up to a 24-day early infusion is allowed
        c. For rheumatoid arthritis treated as often as every 4 weeks, up to a 7-day early infusion is allowed

    Orencia

    • Age restriction of 18 years old and older for rheumatoid arthritis and psoriatic arthritis
    • Age restriction of 2 years old and older for polyarticular juvenile idiopathic arthritis
    • Maximum dose limits based on FDA prescribing information:
      1. 1,000 mg per intravenous infusion
      2. 125 mg per subcutaneous injection

    The drug edits use criteria established by the FDA for drugs administered in the physician office. The criteria are contained in the manufacturer’s package insert and are included in the plan’s specific medical or pharmacy policy.

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