Harvard Pilgrim: Infliximab Medical Review Criteria Update

May 2017 ~

Effective for dates of service beginning May 26, 2017, Harvard Pilgrim will update its commercial and StrideSM (HMO) Medicare Advantage medical review criteria for the medication infliximab (Remicade/Inflectra) to allow coverage for the CPT® code Q5102 (Injection, infliximab, biosimilar, 10 mg).

According to Harvard Pilgrim, medically necessary use of infliximab will be covered with prior authorization for members with any of the following diagnoses:

  • Moderately to severely active rheumatoid arthritis or active psoriatic arthritis
  • Moderately to severely active Crohn’s Disease
  • Fistulizing Crohn’s disease
  • Moderately to severely active pediatric Crohn’s disease
  • Moderately to severely active ulcerative colitis
  • Moderately to severely active pediatric ulcerative colitis
  • Active ankylosing spondylitis
  • Severe plaque psoriasis (i.e., extensive and/or disabling)
  • Non-infectious uveitis (chronic, recurrent, refractory, OR vision-threatening)

To obtain prior authorization for infliximab, providers must meet the criteria as specified in the updated commercial Infliximab (Remicade®/Inflectra) Medical Review Criteria or the StrideSM (HMO) Medicare Advantage Infliximab (Remicade®/Inflectra) Medical Review Criteria.


CPT® is a registered trademark of the American Medical Association.


Source(s): Harvard Pilgrim Network Matters; Leavitt Partners;