Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J6 · Effective Oct 1, 2015
6 active Medicare policies list Q5104, and 31 commercial payer policies list it. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.
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J6 · Effective Oct 1, 2015
JK · Effective Oct 1, 2015
JJ · Effective Oct 1, 2015
JM · Effective Oct 1, 2015
National · Effective Jan 1, 2026
J6 · Effective Oct 1, 2024
31 policies from 13 payers
Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.
Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.
Showing 10 of 11 · All EviCore by Evernorth policies
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab (Remicade, Inflectra, Renflexis, Avsola, Infliximab) Non-oncologyEffective 12/01/2024 - 12/31/2025 | Dec 1, 2024 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Infliximab (Remicade, Inflectra, Renflexis, Avsola, Infliximab)_Non-oncEffective 09/01/2023 - 12/31/2023 | Sep 1, 2023 | Prior auth required |
| Infliximab (Remicade, Inflectra, Renflexis, Avsola, Infliximab)_Non-oncologyEffective 01/01/2024 - 11/30/2024 | Jan 1, 2024 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Infliximab (Remicade, Inflectra, Renflexis, Avsola)Effective 02/01/2021 - 04/30/2021 | Feb 1, 2021 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Infliximab (Remicade, Inflectra, Renflexis, Avsola)Effective 05/01/2021 - 04/30/2022 | May 1, 2021 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Infliximab (Remicade, Inflectra, Renflexis, Avsola)Effective 05/01/2022 - 10/31/2022 | May 1, 2022 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Infliximab (Remicade, Inflectra, Renflexis, Avsola)Effective 11/01/2022 - 08/31/2023 | Nov 1, 2022 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Infliximab (Remicade, Inflectra, Renflexis)Effective 10/01/2019 - 09/30/2020 | Oct 1, 2019 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Infliximab (Remicade, Inflectra, Renflexis)Effective 10/01/2020 - 01/31/2021 | Oct 1, 2020 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Infliximab (Remicade, Inflectra, Renflexis)Effective 11/02/2018 - 09/30/2019 | Nov 2, 2018 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab (Avsola, Inflectra, Remicade, & Renflexis) | Feb 1, 2026 | Covered |
| Provider Administered Drugs – Site of Care | Oct 1, 2026 | Covered |
| Infliximab (Avsola, Inflectra, Remicade, & Renflexis) – Individual Exchange Medical Benefit Drug Policy | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments | Feb 20, 2024 | Covered |
| Infliximab | Feb 15, 2024 | Covered |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab and Associated Biosimilars | Jan 1, 2026 | Covered |
| Specialty Medication Administration Site of Care | Jan 1, 2026 | Covered |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab and Associated Biosimilars | Jan 1, 2026 | Covered |
| Specialty Medication Administration Site of Care | Jan 1, 2026 | Covered |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab and Associated Biosimilars | Jan 1, 2026 | Covered |
| Specialty Medication Administration Site of Care | Jan 1, 2026 | Covered |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab and Associated Biosimilars | Jan 1, 2026 | Covered |
| Specialty Medication Administration Site of Care | Jan 1, 2026 | Covered |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab (Avsola, Inflectra, Remicade, & Renflexis) | Feb 1, 2026 | Covered |
| Provider Administered Drugs – Site of Care | Oct 1, 2026 | Covered |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab Products: Infliximab (Remicade); Infliximab axxq (Avsola), Infliximab dyyb (Inflectra); Infliximab abda (Renflexis); Infliximab-dyyb (Zymfentra), Infliximab | Aug 1, 2000 | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab (Remicade), infliximab-dyyb (Inflectra), and infliximab-abda (Renflexis), infliximab-qbtx (Ixifi), and infliximab-axxq (Avsola) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| 00607 infliximab-abda (Renflexis)- Retired Policy | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab: Remicade; Inflectra; Renflexis; Avsola; Infliximab* | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5104 |
|---|---|---|
| Infliximab (Avsola, Inflectra, Remicade, & Renflexis) | Feb 1, 2026 | Covered |