ND Committee Review
Internal Medical Policy Committee 3-23-2022
Effective April 01, 2022
- Adopted
policy
- WasPreviously
policy number I-28 (same title). Policy has preferred products [i.e., Remicade (infliximab), Infliximab, Inflectra (infliximab-dyyb), Renflexis (infliximab-abda)] and non-preferred product Avsola (infliximab-axxq)
Internal Medical Policy Committee 9-28-2022
Effective January 01, 2023
- Updated
preferred products [i.e., Inflectra (infliximab-dyyb), Renflexis (infliximab-abda)]
and
- Updated
non-preferred products [i.e., Remicade (infliximab), Infliximab, Avsola (infliximab-axxq)]
- Removed
latent tuberculosis criteria from the policy,
and
- Updated
experimental/investigational statement
Internal Medical Policy Committee 1-26-2023
Effective January 26, 2023
- Updated
reauthorization criteria to removed 'the requested agent' to change to: The individual has been previously approved for 'infliximab or an infliximab biosimilar' through the Blue Cross Blue Shield of North Dakota's precertification process;
and
The individual has had clinical benefit with 'infliximab or an infliximab biosimilar'.
Internal Medical Policy Committee 1-16-2024
Effective March 01, 2024
- Separating
Commercial and Medicaid Expansion into separate policies. Commercial will remain I-9028 and Medicaid Expansion will be ME-I-9028-003
- Updated
diagnosis code list
- Updated
agents NOT to be used concomitantly list
Internal Medical Policy Committee 7-16-2024
Effective July 01, 2024
- Added
statement 'The intravenous formulation may be covered under the medical benefit; please refer to pharmacy policies for coverage of the subcutaneous formulation'
Internal Medical Policy Committee 11-19-2024
Effective December 08, 2024