UnitedHealthcare Infliximab (Remicade & Biosimilars) prior authorization requirements (2026)
What UnitedHealthcare generally requires to approve Infliximab (Remicade & Biosimilars) (CPT J1745, Q5103, Q5104, Q5121), for Commercial plans. Yes. UnitedHealthcare generally requires prior authorization for Infliximab (Remicade & Biosimilars) (CPT J1745, Q5103, Q5104, Q5121).
Medical-necessity criteria UnitedHealthcare generally applies
Medical benefit drug policy. Inflectra (infliximab-dyyb) and Avsola (infliximab-axxq) are the preferred products (non-preferred require a documented trial of a preferred product of about 14 weeks, or intolerance/contraindication). RHEUMATOID ARTHRITIS (prescribed by/with a rheumatologist): moderately-to-severely active RA AND one of: failure/intolerance to a 3-month trial of a non-biologic DMARD (methotrexate, leflunomide, sulfasalazine, hydroxychloroquine) at maximally indicated doses within the last 6 months unless contraindicated; OR prior treatment with an RA-approved targeted immunomodulator; OR currently on infliximab. CROHN'S DISEASE: one of high-risk disease (fistulizing, stricturing, perianal, extensive, or growth delay), failure of a conventional therapy (corticosteroids, 6-mercaptopurine, azathioprine, methotrexate), prior CD-approved targeted immunomodulator, or current infliximab. ULCERATIVE COLITIS: failure/intolerance to a conventional therapy (6-mercaptopurine, aminosalicylate, azathioprine, corticosteroids), prior UC-approved targeted immunomodulator, or current infliximab. Dosed per FDA labeling; initial authorization up to 12 months.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Infliximab (Remicade & Biosimilars). Confirm the covered diagnosis list against the current UnitedHealthcare policy.
Commonly required documentation
- Diagnosis
- documented conventional-therapy or prior-biologic history
- preferred-product trial/intolerance documentation
- FDA-compliant dosing.
Situations to verify before submitting
UnitedHealthcare may not cover Infliximab (Remicade & Biosimilars) in these situations. Verify against the current policy rather than assuming a denial:
- Not covered in combination with another systemic targeted immunomodulator for the same indication
How to submit
- Method: UnitedHealthcare provider portal (medical benefit drug review)
- Portal: UnitedHealthcare Provider Portal
Sources & verification
Source: UHC Commercial Medical Benefit Drug Policy 2026D0004AR Infliximab (eff 2026-02-01). Codes J1745, Q5103, Q5104, Q5121. Last verified 2026-06-17.
Frequently asked questions
Does UnitedHealthcare require prior authorization for Infliximab (Remicade & Biosimilars)?
Yes. UnitedHealthcare generally requires prior authorization for Infliximab (Remicade & Biosimilars) (CPT J1745, Q5103, Q5104, Q5121).
What does UnitedHealthcare require to approve Infliximab (Remicade & Biosimilars)?
Medical benefit drug policy. Inflectra (infliximab-dyyb) and Avsola (infliximab-axxq) are the preferred products (non-preferred require a documented trial of a preferred product of about 14 weeks, or intolerance/contraindication). RHEUMATOID ARTHRITIS (prescribed by/with a rheumatologist): moderately-to-severely active RA AND one of: failure/intolerance to a 3-month trial of a non-biologic DMARD (… Always confirm against the current UnitedHealthcare policy.
How long does a UnitedHealthcare prior authorization take?
Turnaround varies by plan and submission method. Check the UnitedHealthcare portal for current timeframes.
Submitting Infliximab (Remicade & Biosimilars) to UnitedHealthcare?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.