Renflexis (infliximab-abda)
Billing
Code: Q5104
Description: Injection, renflexis
Unit: 10 mg
Payment: $32.562
Pay quarter: Q4 2023
Dosage and Frequency
Crohn's Disease (CD)
Ulcerative Colitis (UC)
Ankylosing Spondylitis (AS)
Psoriatic Arthritis (PsA)
Plaque Psoriasis (Ps)
Induction:
• 5mg/kg IV at 0, 2, and 6 weeks
Maintenance:
• 5mg/kg IV every 8 weeks
Ulcerative Colitis (UC)
Ankylosing Spondylitis (AS)
Psoriatic Arthritis (PsA)
Plaque Psoriasis (Ps)
Induction:
• 5mg/kg IV at 0, 2, and 6 weeks
Maintenance:
• 5mg/kg IV every 8 weeks
Rheumatoid Arthritis (RA)
Induction:
• 3mg/kg IV at 0, 2, and 6 weeks
Maintenance:
• 3mg/kg IV every 8 weeks
Induction:
• 3mg/kg IV at 0, 2, and 6 weeks
Maintenance:
• 3mg/kg IV every 8 weeks
Calculate drug reimbursement
Total Reimbursement:
$976.86(ASP: $921.57, Margin: $55.29)
Code:
Q5104# Units to bill:
30Prior Authorization
Prior auth criteria for Renflexis may include but is not limited to:
1. The patient must have a diagnosis of Rheumatoid Arthritis, Ankylosing Spondylitis, or Psoriatic Arthritis that is documented in the medical record.
2. The patient must have had an inadequate response to at least one TNF inhibitor therapy.
3. The patient must have an established diagnosis of moderate to severe chronic inflammatory arthritis for at least 6 months.
4. The patient must be 18 years of age or older.
5. The patient must have a body mass index (BMI) of less than 40 kg/m2.
6. The patient must have normal liver function tests.
7. The patient must have had a negative pregnancy test (in women of childbearing potential).
8. The patient must not have any active infections.
9. The patient must not have any other serious medical conditions that may increase the risk of Renflexis.
Insurance prior auth guidelines:
Billable NDCs
00006-4305-02
Renflexis (MERCK SHARP & DOHME CORP.)
100 MG
78206-0162-01
Renflexis (ORGANON LLC)
100 MG
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