HCPCS
J1745
1 unit = 10 mg
Phase 1
Identify what you're billing
Five products, one unit basis (10 mg). Confirm code, dose, and NDC before billing.
Five infliximab products — the disambiguation table CMS HCPCS + FDA verified May 2026
Reference originator and four biosimilars. All share one unit basis (10 mg), the same FDA boxed warnings, and the same indication panel, but each has its own HCPCS code, NDC, manufacturer, and ASP.
| HCPCS | Brand | Mfr | Generic | HCPCS descriptor | Q2 2026 ASP+6% / 10 mg |
|---|---|---|---|---|---|
J1745 |
Remicade (originator) | Janssen Biotech | infliximab | "Injection, infliximab, excludes biosimilar, 10 mg" | $31.041 |
Q5103 |
Inflectra | Pfizer / Celltrion | infliximab-dyyb | "Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mg" | $26.035 |
Q5104 |
Renflexis | Samsung Bioepis / Organon | infliximab-abda | "Injection, infliximab-abda, biosimilar, (Renflexis), 10 mg" | $26.803 |
Q5121 |
Avsola | Amgen | infliximab-axxq | "Injection, infliximab-axxq, biosimilar, (Avsola), 10 mg" | $28.040 |
Q5109 |
Ixifi | Pfizer | infliximab-qbtx | "Injection, infliximab-qbtx, biosimilar, (Ixifi), 10 mg" | N/A — see note |
Q5109 Ixifi: not in the CMS Q2 2026 ASP file — product is discontinued / limited
commercial supply in the United States. ASP unavailable. If a payer or chart references Ixifi for a
historical claim, verify the date of service and consult the relevant quarterly ASP file. Active
formulary biosimilar choices in 2026 are Inflectra (Q5103), Renflexis (Q5104), and Avsola (Q5121).
Three reference-error patterns to avoid:
- Unit basis: all five infliximab codes are 10 mg per unit. Many billers default to "1 mg per unit" (the standard for most J-codes). For infliximab, divide milligrams by 10 to get the unit count.
- Brand-to-code mapping: Q5103 = Inflectra (Pfizer/Celltrion); Q5104 = Renflexis (Organon/Samsung Bioepis); Q5121 = Avsola (Amgen); Q5109 = Ixifi (Pfizer). Always verify against the manufacturer’s billing PDF and the AAPC code lookup.
- Chemo vs. non-chemo admin: infliximab is non-cytotoxic. Use 96365 + 96366. Do NOT use 96413/96415 (those are for chemotherapy / cytotoxic biologics like rituximab in NHL/CLL).
All five products carry the same FDA boxed warnings (serious infections including TB reactivation; malignancies including HSTCL in IBD patients on combination therapy with thiopurines). Pre-treatment latent TB screening (PPD or IGRA) and HBV serology are standard of care for any infliximab product.
IV (J1745/Q5103/Q5104/Q5121/Q5109) vs. Zymfentra SC FDA labels verified 2025–2026
Zymfentra (infliximab-dyyb subcutaneous) is a separate specialty-pharmacy product for maintenance after IV induction. It does NOT bill under any of the J/Q infliximab codes.
| IV products (J1745, Q5103, Q5104, Q5121, Q5109) | Zymfentra (Remsima SC) | |
|---|---|---|
| HCPCS | J1745 / Q5103 / Q5104 / Q5121 / Q5109 (medical benefit) | Not a J-code — specialty pharmacy SC under separate codes |
| Generic | infliximab (originator) / -dyyb / -abda / -axxq / -qbtx | infliximab-dyyb (subcutaneous) |
| Manufacturer | Janssen / Pfizer-Celltrion / Organon-Samsung Bioepis / Amgen / Pfizer | Celltrion (US distribution) |
| Route | Intravenous infusion (≥2 hours) | Subcutaneous self-injection |
| Phase of care | Induction (0/2/6 weeks) AND maintenance | Maintenance only — after IV induction tolerated |
| Site of admin | Office, AIC, hospital outpatient | Patient home / self-administered |
| Benefit channel | Medical (provider buy-and-bill) | Pharmacy (specialty) |
| Indications (FDA) | RA, AS, PsA, plaque psoriasis, CD, UC | Crohn's disease and ulcerative colitis (maintenance) |
Why this matters for billing: a patient transitioning from IV induction to SC maintenance
will appear on two different benefits (medical vs. pharmacy). The IV induction (0/2/6 wks) bills under
Remicade or a biosimilar J/Q code. The SC maintenance (Zymfentra) drops off the medical claim feed entirely
— do not look for it under the infliximab J-codes when reconciling.
Dosing per indication FDA labels + Janssen / biosimilar manufacturer billing PDFs
All indications: weight-based mg/kg dosing. Standard induction is at 0, 2, and 6 weeks, then maintenance per indication.
| Indication | Induction | Maintenance | Notes |
|---|---|---|---|
| Rheumatoid arthritis (RA) | 3 mg/kg IV at weeks 0, 2, 6 | 3 mg/kg q8wk thereafter | Required combination with methotrexate. May escalate to 10 mg/kg q4wk for inadequate response. |
| Ankylosing spondylitis (AS) | 5 mg/kg IV at weeks 0, 2, 6 | 5 mg/kg q6wk thereafter | Per FDA label. |
| Psoriatic arthritis (PsA) | 5 mg/kg IV at weeks 0, 2, 6 | 5 mg/kg q8wk thereafter | With or without methotrexate. |
| Plaque psoriasis | 5 mg/kg IV at weeks 0, 2, 6 | 5 mg/kg q8wk thereafter | Adult patients with chronic severe plaque psoriasis. |
| Crohn's disease (adult) | 5 mg/kg IV at weeks 0, 2, 6 | 5 mg/kg q8wk thereafter | Moderate-to-severe and fistulizing CD. May escalate to 10 mg/kg for loss of response. |
| Pediatric Crohn's disease | 5 mg/kg IV at weeks 0, 2, 6 (ages 6+) | 5 mg/kg q8wk thereafter | Same dosing schedule as adults; weight calculated by kg. |
| Ulcerative colitis (adult) | 5 mg/kg IV at weeks 0, 2, 6 | 5 mg/kg q8wk thereafter | Moderate-to-severe UC. |
| Pediatric ulcerative colitis | 5 mg/kg IV at weeks 0, 2, 6 (ages 6+) | 5 mg/kg q8wk thereafter | Same dosing schedule as adults. |
Unit conversion shortcut: mg ÷ 10 = units. Worked weight-based examples
(single-dose vials are 100 mg each, so the number of vials drawn rounds up):
- RA, 70 kg patient at 3 mg/kg = 210 mg administered → 21 units; 3 vials drawn (300 mg) → 90 mg = 9 units waste (JW)
- Crohn's, 75 kg patient at 5 mg/kg = 375 mg administered → 38 units (round per MAC); 4 vials drawn (400 mg) → 25 mg = 2.5 units waste (JW)
- AS, 80 kg patient at 5 mg/kg = 400 mg administered → 40 units; 4 vials drawn, no waste (JZ only)
- RA dose escalation, 80 kg patient at 10 mg/kg = 800 mg → 80 units; 8 vials drawn, no waste (JZ only)
Premedications
Premedication varies per protocol and prior-reaction history. Common regimens include diphenhydramine (antihistamine), acetaminophen, and hydrocortisone (for selected patients with prior infusion reactions or higher-risk profiles). Premed administration is billed as separate admin codes (96372 IM/SC, or 96374 IV push) with the appropriate J-code for each agent. The per-protocol decision sits with the prescribing clinician.
First-dose administration setting
Because of the FDA-flagged risk of acute infusion reactions and the ~2-hour minimum infusion time, first doses are typically administered in a setting with immediate access to resuscitation (hospital outpatient, AIC, or office equipped with emergency medications). Subsequent doses can move to lower-cost sites of care per payer site-of-care UM rules.
NDC reference — all five products FDA NDC Directory verified May 2026
Pad to 11 digits with a leading zero in the appropriate segment for CMS-1500 Box 24A.
Remicade (J1745) — Janssen Biotech labeler 57894
| NDC (10-digit) | NDC (11-digit, claim form) | Package |
|---|---|---|
57894-030-01 | 57894-0030-01 | 100 mg single-dose lyophilized vial |
Inflectra (Q5103) — Pfizer labeler 0069
| NDC (10-digit) | NDC (11-digit, claim form) | Package |
|---|---|---|
0069-0809-01 | 00069-0809-01 | 100 mg single-dose lyophilized vial |
Renflexis (Q5104) — Organon / Samsung Bioepis labeler 78206
| NDC (10-digit) | NDC (11-digit, claim form) | Package |
|---|---|---|
78206-145-01 | 78206-0145-01 | 100 mg single-dose lyophilized vial |
Avsola (Q5121) — Amgen labeler 55513
| NDC (10-digit) | NDC (11-digit, claim form) | Package |
|---|---|---|
55513-203-01 | 55513-0203-01 | 100 mg single-dose lyophilized vial |
Ixifi (Q5109) — Pfizer labeler 0069 — discontinued / limited supply
| NDC (10-digit) | NDC (11-digit, claim form) | Package |
|---|---|---|
0069-0331-01 | 00069-0331-01 | 100 mg single-dose lyophilized vial — verify availability before billing |
11-digit NDC required on most claim forms. Pad the labeler-product-package segments to
5-4-2. Pfizer labeler 0069 pads to 00069:
0069-0809-01 →
00069-0809-01. Use N4 qualifier in CMS-1500 Box 24A shaded area with unit of
measure (UN for unit / each is typical for lyophilized vials — verify per MAC) and quantity actually
drawn from the vial.
Phase 2
Code the claim
Non-chemo IV admin codes. JZ + JW per CMS rules — JW common because of mg/kg dosing.
Administration codes CPT verified May 2026
Infliximab is non-cytotoxic biologic — therapeutic IV infusion codes (96365 + 96366), NOT chemotherapy admin codes (96413/96415).
NON-CHEMO — do NOT use 96413 / 96415. Infliximab is an anti-TNF monoclonal
antibody, not a cytotoxic agent. Using chemotherapy admin codes is a documented denial trigger for many
commercial payers and is technically incorrect per AMA CPT guidance. The duration of the infusion (≥2
hours) does not change the code family.
| CPT | Description | Use for |
|---|---|---|
96365 |
Therapeutic, prophylactic or diagnostic IV infusion; up to 1 hour | First hour of infliximab infusion — standard for all 5 products, all indications |
96366 |
Therapeutic IV infusion; each additional hour | Hours 2+ of infliximab infusion (typical induction = 2 hrs → 1 unit 96365 + 1 unit 96366) |
96413 |
Chemotherapy administration, IV infusion; up to 1 hour, single or initial substance | NOT APPROPRIATE — infliximab is non-cytotoxic. Frequent biller error. |
96415 |
Chemotherapy administration, IV infusion; each additional hour | NOT APPROPRIATE — same as 96413; reserved for cytotoxic agents. |
96367 |
IV infusion, additional sequential infusion of new substance | Concurrent premed infusions (separate substance) per AMA hierarchy rules |
96374 |
Therapeutic IV push, single drug | IV-push premedications (e.g., diphenhydramine, hydrocortisone) |
96372 |
Therapeutic SC/IM injection | SC/IM premedications |
Premedications
Premed regimens vary by protocol and prior-reaction history. Common agents: diphenhydramine (antihistamine; oral or IV push), acetaminophen (oral), and hydrocortisone (IV push, for selected patients). Bill each premed J-code on its own line; admin per the appropriate CPT (96372 IM/SC, 96374 IV push). Watch the AMA infusion hierarchy: only one initial code per encounter.
Modifiers — JZ, JW, and the mg/kg waste calculation CMS verified May 2026
JW applies to most infliximab infusions because dosing is weight-based and 100 mg vials rarely match the calculated dose exactly.
JZ — required when no drug discarded
Effective July 1, 2023, CMS requires the JZ modifier on all single-dose container claims when no drug is discarded. For infliximab, JZ applies when the calculated mg dose is an exact multiple of 100 mg (the vial size) — e.g., 80 kg patient at 5 mg/kg = 400 mg = exactly 4 vials, no waste; 80 kg at 10 mg/kg = 800 mg = exactly 8 vials. Append JZ to the J1745 / Q5103 / Q5104 / Q5121 / Q5109 line.
JW — required for documented waste of unused single-dose-vial drug
For most weight-and-dose combinations, the calculated mg dose is not an exact multiple of 100 mg, so partial-vial waste is the rule. CMS requires the JW modifier on a separate claim line for the discarded units (rounded per CMS rules), with the wastage documented in the medical record. Bill administered units (with JZ) and discarded units (with JW) on two separate lines, same date of service, same HCPCS code.
Worked JW example — Remicade, Crohn's disease, 75 kg patient at 5 mg/kg:
Calculated dose: 5 mg/kg × 75 kg = 375 mg
Vials drawn: 4 × 100 mg = 400 mg total
Administered: 375 mg
Discarded: 400 − 375 = 25 mg
Convert to units (1 unit = 10 mg):
Administered units: 375 / 10 = 37.5 → round per CMS rules
Discarded units: 25 / 10 = 2.5 → round per CMS rules
Claim lines (J1745):
Line 1: J1745 · JZ · ~38 units (administered)
Line 2: J1745 · JW · ~3 units (discarded)
Apply each MAC’s rounding convention. Some MACs require billing the total drawn from the vial as administered units and reporting waste only when the discard amount triggers it. Refer to your local MAC billing article for the exact rounding rule.
JG / TB — 340B drug pricing
Hospitals that purchase infliximab through 340B and bill Medicare report the JG modifier (acute-care hospitals) or TB modifier (rural sole community / critical-access hospitals), per CMS guidance. Most infusion suites do not use 340B pricing; only the hospital-outpatient setting does.
Modifier 25 — same-day E/M
Append modifier 25 to the same-day E/M code if a significant, separately identifiable evaluation occurred (clinical reassessment for next-cycle decision, treatment-decision encounter, etc.). Routine pre-infusion check-in is bundled.
ICD-10-CM diagnosis codes FY2026 verified May 2026
Use the most specific code supported by chart documentation. Each indication has a distinct code family.
| Indication | ICD-10 family | Examples |
|---|---|---|
| Rheumatoid arthritis (RA) | M05.x / M06.x |
M05.79 (RA w/ rheumatoid factor multiple sites w/o organ involvement); M06.09 (RA w/o RF, multi-site); M05.9 (RA w/ RF unspecified) |
| Ankylosing spondylitis (AS) | M45.x |
M45.0 (AS, multiple sites in spine); M45.9 (AS unspecified); M45.1–M45.8 (site-specific) |
| Psoriatic arthritis (PsA) | L40.5x / M07.x |
L40.50 (arthropathic psoriasis unspec); L40.51 (distal interphalangeal psoriatic arthropathy); L40.52 (psoriatic arthritis mutilans); L40.59 (other psoriatic arthropathy) |
| Plaque psoriasis | L40.x |
L40.0 (psoriasis vulgaris — plaque psoriasis); L40.9 (psoriasis unspecified) |
| Crohn's disease (adult + pediatric) | K50.x |
K50.00/K50.01x (Crohn's small intestine); K50.10/K50.11x (large intestine); K50.80/K50.81x (both); K50.90/K50.91x (unspecified) |
| Ulcerative colitis (adult + pediatric) | K51.x |
K51.00/K51.01x (UC, ulcerative pancolitis); K51.20/K51.21x (UC, proctitis); K51.30/K51.31x (rectosigmoiditis); K51.50/K51.51x (left-sided colitis); K51.80/K51.81x (other UC); K51.90/K51.91x (UC unspecified) |
Pair the diagnosis with the right product. All five infliximab products share the same
FDA indication panel (RA, AS, PsA, plaque psoriasis, Crohn's, UC). The biosimilar HCPCS codes (Q5103,
Q5104, Q5121, Q5109) are interchangeable in indication scope with reference Remicade (J1745) for billing
purposes — they differ only in HCPCS code, NDC, ASP, and payer preference.
Site of care & place of service Verified May 2026
First dose typically office, AIC, or hospital outpatient depending on payer site-of-care UM and reaction-risk profile. Subsequent doses move to lowest-cost site allowed by the plan.
| Setting | POS | Claim form | Electronic | Typical use |
|---|---|---|---|---|
| Physician office / infusion suite | 11 | CMS-1500 | 837P | Most maintenance doses; rheumatology / GI office |
| Ambulatory infusion center (AIC) | 49 | CMS-1500 | 837P | Maintenance post site-of-care steering |
| On-campus hospital outpatient | 22 | UB-04 / CMS-1450 | 837I | First dose, reaction history, complex patients |
| On-campus hospital outpatient (alt) | 19 | UB-04 / CMS-1450 | 837I | First dose, hospital-affiliated |
| Off-campus hospital outpatient | 19 | UB-04 / CMS-1450 | 837I | First dose at off-campus HOPD |
| Patient home | 12 | CMS-1500 | 837P | Home infusion permitted by some payers (REMS-equivalent supervision; verify) |
Payer site-of-care steering
UnitedHealthcare, Aetna, Cigna, and most BCBS plans apply site-of-care UM to specialty infusion drugs. After tolerated infusions, payers typically require subsequent doses to move out of HOPD (POS 19/22) into office (POS 11) or an in-network AIC (POS 49) where facility fees are lower. Infliximab is one of the highest-volume drugs targeted by site-of-care optimization given the q8wk maintenance cadence.
POS choice affects total reimbursement. Office (POS 11) and AIC (POS 49) generally pay
the drug at the physician fee schedule with separate admin codes; hospital outpatient (POS 19/22) bills
under OPPS/APC packaging with separate facility-fee considerations. Confirm payer site preference before
scheduling beyond the first infusion.
Claim form field mapping Janssen / Pfizer / Organon / Amgen billing PDFs
CMS-1500 / 837P (physician office, AIC; POS 11/49) example for a 5 mg/kg Crohn's dose of J1745, 75 kg patient.
| Information | CMS-1500 box | Notes |
|---|---|---|
| NDC qualifier + 11-digit NDC + UoM + qty | 24A shaded area | Format: N457894003001UN4 for four 100 mg vials drawn (UN qualifier — verify per MAC) |
| HCPCS J1745 + JZ | 24D (drug line) | Administered units (e.g., 38 units for a 375 mg Crohn's dose, per MAC rounding) |
| HCPCS J1745 + JW (when waste) | 24D (separate line) | Discarded units (e.g., 3 units for 25 mg waste, per MAC rounding) |
| Drug units | 24G | Administered + waste split across two lines, same DOS |
| CPT 96365 + 96366 | 24D (admin lines) | 1 unit 96365 (initial hour) + 1 unit 96366 (each additional hour) — non-chemo |
| ICD-10 | 21 | Indication-specific (M05.x RA; M45.x AS; L40.x psoriasis; K50.x CD; K51.x UC) |
| Dates of service | 24A | Same date for drug + admin lines |
| NPI | 17b / 24J / 33a | Rendering and billing provider NPI |
| PA number (when required) | 23 | Required by UHC, Aetna, most BCBS for non-preferred Remicade in 2026 |
| JG / TB modifier (340B sites only) | 24D | Hospital outpatient 340B claims only |
Source: Janssen Remicade Billing & Coding Guide; Pfizer Inflectra billing reference; Organon Renflexis coding guide; Amgen Avsola Reimbursement Resource Center.
Phase 3
Get paid
2026 is the biosimilar-mandatory year for many payers. PBM private-label products further steer to specific biosimilars.
Payer policy snapshot — biosimilar mandates 2026 Reviewed May 2026
National payers have moved decisively to biosimilar-mandatory or strongly preferred policies for infliximab. PBM private-label biosimilars (Cordavis, Quallent, Nuvaila) further narrow the choice.
| Payer | PA? | Preferred / mandated | Reference Remicade? | Notes |
|---|---|---|---|---|
| UnitedHealthcare Commercial + MA |
Yes | Biosimilar mandatory (Inflectra, Renflexis, Avsola) | Denied unless documented medical necessity (intolerance to all biosimilars or specific clinical contraindication) | Strictest infliximab policy among national payers in 2026 |
| Aetna Commercial |
Yes | Lowest-cost biosimilar preferred | Allowed only with step-therapy failure / clinical justification | Specific biosimilar steering varies by plan and PBM contract |
| Cigna Commercial / ESI |
Yes | Biosimilar preferred — ESI Quallent private-label may steer to specific product | Step therapy through biosimilar required for new starts | Quallent is ESI's private-label biosimilar division |
| BCBS (most plans) Plan-by-plan |
Yes | Biosimilar-preferred (most plans); some now biosimilar-mandatory | Verify per plan; many require step therapy | Trending toward UHC-style mandates through 2026 |
| OptumRx (UHG PBM) Nuvaila private-label |
Yes | Nuvaila private-label biosimilar (Inflectra-distributed) | Generally non-preferred | Nuvaila is OptumRx's private-label biosimilar (launched 2024) |
| CVS Caremark Cordavis private-label |
Yes | Cordavis private-label biosimilar (Inflectra-distributed) | Generally non-preferred | Cordavis is CVS Health's biosimilar subsidiary (launched 2023) |
UnitedHealthcare commercial: reference Remicade (J1745) is denied unless the prescriber
documents medical necessity for the originator (e.g., documented intolerance to multiple biosimilars or
a specific contraindication). UHC accepts Inflectra (Q5103), Renflexis (Q5104), and Avsola (Q5121) as
preferred. New-patient starts on J1745 will require comprehensive step-therapy documentation.
PBM private-label biosimilars (CVS Cordavis, ESI Quallent, OptumRx Nuvaila): these are
repackaged distributor labels for existing FDA-approved biosimilars (predominantly Inflectra). They steer
plan utilization to a specific biosimilar with deeper net pricing for the PBM. The HCPCS code stays the
same (Q5103 for Inflectra-sourced product) — the steering is at the formulary/network level, not the
billing-code level. Confirm which biosimilar your patient’s plan actually covers before drawing the
vial.
What to document for biosimilar approval / Remicade override
- Brand of biosimilar tried (Inflectra, Renflexis, Avsola), HCPCS code, dates of administration
- Number of doses or duration of trial (most policies: at least one full induction cycle 0/2/6 + at least one maintenance dose)
- Documented intolerance, infusion-reaction, or inadequate response (with objective measures: disease activity scores, endoscopy findings for IBD, imaging for inflammatory arthritis)
- Any clinical contraindication to the biosimilar pathway (rare; biosimilars share the same molecular structure)
Medicare reimbursement CMS Q2 2026 (live)
Quarterly ASP from CMS Part B Drug Pricing File. Four of five infliximab codes refresh together each quarter (Ixifi Q5109 has no current ASP).
Q2 2026 payment snapshot — J1745 reference Remicade
Effective April 1 – June 30, 2026 · Based on 4Q25 ASP submissions
ASP + 6%
$31.041
per 10 mg unit
350 mg dose (5 mg/kg, 70 kg)
$1,086.44
35 units × ASP+6%
After sequestration
~$1,065
~2% reduction (actual paid)
Cross-product price comparison (Q2 2026 ASP+6%)
| Code | Brand | Per 10 mg unit | Per 350 mg dose (5 mg/kg, 70 kg) | vs. J1745 |
|---|---|---|---|---|
J1745 | Remicade | $31.041 | $1,086.44 | baseline |
Q5103 | Inflectra | $26.035 | $911.23 | ~16% lower |
Q5104 | Renflexis | $26.803 | $938.11 | ~14% lower |
Q5121 | Avsola | $28.040 | $981.40 | ~10% lower |
Q5109 | Ixifi | N/A | N/A | Discontinued / no current ASP |
Coverage
No NCD specific to infliximab as a class. Each MAC publishes a billing & coding article covering infliximab and biosimilars with covered ICD-10 ranges per indication (RA, AS, PsA, plaque psoriasis, Crohn's, UC). All MACs cover J1745, Q5103, Q5104, Q5121, and (historically) Q5109 for FDA-approved on-label indications. Bill with the indication-specific ICD-10 (see ICD-10 by indication).
Canonical code source: CMS HCPCS quarterly update file.
Patient assistance — one program per manufacturer Manufacturer sites verified May 2026
- Remicade (J1745) — Janssen CarePath: 1-877-CarePath (1-877-227-3728). Janssen CarePath Savings Program for eligible commercially-insured patients. Janssen Patient Assistance Foundation for free drug to qualifying uninsured / underinsured patients. Independent foundations (PAN, HealthWell) for Medicare patients — verify open funds quarterly.
- Inflectra (Q5103) — Pfizer Encompass / Celltrion Connect: Pfizer Encompass for benefit verification, PA support, and copay assistance for eligible commercially-insured patients. Celltrion Connect (joint program with Celltrion). Pfizer Patient Assistance Program for free drug to qualifying uninsured patients.
- Renflexis (Q5104) — Organon Patient Support: Organon (formerly part of Merck) Patient Support program; Samsung Bioepis is the originating manufacturer. Copay assistance for eligible commercially-insured patients; PAP for uninsured/underinsured.
- Avsola (Q5121) — Amgen Assist 360: 1-888-427-7478. Amgen SupportPlus copay program for eligible commercially-insured patients. Amgen Safety Net Foundation for free drug to qualifying uninsured patients.
- Ixifi (Q5109) — Pfizer Encompass: historical Pfizer support program; verify current availability given limited commercial supply.
Need to model what a specific patient will actually pay after copay assistance, deductible, coinsurance,
and OOP max? Run a CareCost Estimate — J1745 (and all four sibling
codes) pre-loaded.
Phase 4
Fix problems
Top three: chemo-vs-non-chemo admin error, missing JW on weight-based claims, biosimilar mandate not met.
Common denials & how to fix them
| Denial reason | Common cause | Fix |
|---|---|---|
| Wrong admin codes (96413/96415 used) | Biller defaulted to chemo admin codes due to long infusion time | Resubmit with 96365 + 96366 (therapeutic IV, non-chemo). Infliximab is non-cytotoxic. |
| Wrong unit count (10× over- or under-bill) | Biller defaulted to 1 mg/unit (most J-codes) instead of 10 mg/unit (infliximab) | Recalculate: mg ÷ 10 = units. 350 mg = 35 units, not 350. |
| Wrong J-code (J1745 instead of biosimilar) | Reference Remicade billed when patient received Inflectra/Renflexis/Avsola | Verify drug administered. Match HCPCS to NDC drawn: Q5103/Q5104/Q5121/Q5109 each have distinct labelers. |
| Biosimilar mandate not met (UHC) | New start on J1745 without documented biosimilar trial or contraindication | Submit biosimilar trial documentation OR clinical justification (intolerance / contraindication) for Remicade override. |
| JZ missing | Single-dose-vial claim without JZ when no drug was discarded | Resubmit with JZ on the J1745 / Q5103 / Q5104 / Q5121 line. |
| JW missing on weight-based claim | mg/kg dose with vial waste not reported | Add separate line with JW for discarded units (per CMS rounding); document waste in chart. |
| TB screening not documented | Audit-vulnerable; payer requests pre-treatment latent TB testing per FDA boxed warning | Confirm pre-treatment PPD or IGRA result in chart; supply on appeal. Required for all infliximab products. |
| HBV screening not documented | Audit-vulnerable; payer requests pre-treatment HBV serology | Confirm pre-treatment HBsAg + anti-HBc results in chart; supply on appeal. |
| Combination-with-MTX requirement (RA only) | RA dose billed without methotrexate documentation in chart | Per FDA label, Remicade for RA is approved IN COMBINATION with methotrexate. Document MTX use in chart and supply on appeal. |
| Site-of-care denial post first dose | Subsequent infusion at HOPD when payer requires office/AIC | Move infusion to POS 11 or 49; or submit medical-necessity justification (e.g., recurrent reaction history). |
| NDC format / qualifier missing | 10-digit NDC submitted; missing N4 qualifier or unit-of-measure | Use 11-digit NDC with N4 qualifier in CMS-1500 Box 24A shaded area; report appropriate UoM (UN typical for lyophilized vials — verify per MAC) and quantity. |
| Looking for Zymfentra under J1745 | Zymfentra (SC infliximab-dyyb) does not appear on medical-benefit claim feed | Zymfentra is a specialty-pharmacy SC product, not under the J/Q infliximab codes. Reconcile via pharmacy benefit, not medical. |
Frequently asked questions
What are the HCPCS codes for infliximab?
There are five infliximab HCPCS codes: J1745 (Remicade — originator),
Q5103 (Inflectra — infliximab-dyyb), Q5104 (Renflexis —
infliximab-abda), Q5121 (Avsola — infliximab-axxq), and Q5109
(Ixifi — infliximab-qbtx, discontinued / limited supply). All five share the same billing unit
basis: 1 unit = 10 mg. Note: Remsima SC / Zymfentra (subcutaneous infliximab-dyyb) is
NOT a J-code — it bills as specialty pharmacy under separate codes.
How many units do I bill for an infliximab dose?
All five infliximab codes use 1 unit = 10 mg. Convert mg to units by dividing by 10. Examples: a 70 kg RA patient at 3 mg/kg = 210 mg = 21 units; a 75 kg Crohn's patient at 5 mg/kg = 375 mg = 38 units (3 vials drawn would be 300 mg, so 4 vials = 400 mg, 25 mg waste); an 80 kg AS patient at 5 mg/kg = 400 mg = 40 units (4 vials, no waste). Vials are 100 mg single-dose lyophilized — reconstitute with 10 mL sterile water for injection.
Are infliximab admin codes chemo or non-chemo?
NON-CHEMO. Infliximab is a non-cytotoxic biologic (anti-TNF monoclonal antibody) —
bill 96365 (therapeutic IV infusion, initial hour) plus 96366 (each additional
hour). Do NOT use 96413 / 96415 (chemotherapy administration codes). This is a
frequent biller error: rituximab and other oncology biologics use 96413/96415, but infliximab is
therapeutic and gets non-chemo admin codes regardless of indication. Standard infusion is ≥2 hours.
Why does the JW modifier apply more often to infliximab than to fixed-dose drugs?
Infliximab dosing is weight-based (mg/kg) for every indication, so partial-vial waste from 100 mg single-dose vials is the rule. A 75 kg Crohn's patient at 5 mg/kg = 375 mg = 4 vials drawn (400 mg), 25 mg = 2.5 units discarded. Bill JZ on the administered units line and JW on a separate line for the discarded units, with waste documented in the medical record.
Why does the biller need to distinguish Remicade from biosimilars?
Each infliximab product has its own HCPCS code, NDC, and ASP. Billing reference Remicade
(J1745) when the patient received Inflectra (Q5103) is a denial trigger. As of
2026, UnitedHealthcare requires biosimilar use unless documented medical necessity for Remicade. Aetna
and Cigna prefer the lowest-cost option. PBM private-label biosimilars (CVS Cordavis, ESI Quallent,
OptumRx Nuvaila) frequently steer to Inflectra or Avsola.
What is the dosing for infliximab by indication?
Standard regimens (all IV induction at 0, 2, 6 weeks, then maintenance):
- RA = 3 mg/kg q8wk in combination with methotrexate (may escalate to 10 mg/kg q4wk)
- Ankylosing spondylitis = 5 mg/kg q6wk
- Psoriatic arthritis = 5 mg/kg q8wk
- Plaque psoriasis = 5 mg/kg q8wk
- Crohn's disease (adult and pediatric) = 5 mg/kg q8wk
- Ulcerative colitis (adult and pediatric) = 5 mg/kg q8wk
What is the Q2 2026 Medicare reimbursement for J1745 Remicade?
Q2 2026 ASP + 6% for J1745 (reference Remicade) is approximately $31.041 per 10 mg unit. A 5 mg/kg dose for a 70 kg patient = 350 mg = 35 units × $31.041 = $1,086.44 before sequestration. Biosimilars are cheaper: Q5103 Inflectra ~$26.035/unit, Q5104 Renflexis ~$26.803/unit, Q5121 Avsola ~$28.040/unit. Q5109 Ixifi has no current ASP. ASP refreshes quarterly — see the live snapshot above.
What FDA boxed warnings apply to all infliximab products?
All five infliximab products carry the same FDA boxed warnings: (1) serious infections — TB reactivation (latent TB screening required pre-therapy with PPD or IGRA), invasive fungal infections (histoplasmosis, coccidioidomycosis, blastomycosis), bacterial sepsis, opportunistic pathogens; (2) malignancies — lymphoma and other malignancies, including hepatosplenic T-cell lymphoma (HSTCL, mostly fatal) in adolescent and young adult patients receiving infliximab plus thiopurines (azathioprine, 6-MP) for IBD. Pre-therapy TB screening is standard of care.
Is Remsima SC / Zymfentra the same as Remicade?
No. Zymfentra (infliximab-dyyb subcutaneous, marketed by Celltrion) is a subcutaneous formulation approved for maintenance use after IV induction for Crohn's disease and ulcerative colitis. It is NOT billed under any of the J/Q infliximab codes — it dispenses through specialty pharmacy under separate billing codes. Patients on Zymfentra still typically receive IV infliximab (Remicade or a biosimilar) for the 0/2/6 induction phase before switching to SC maintenance.
Reference
Sources & methodology
Every claim on this page is sourced. Methodology and review history below.
Source documents
- AAPC — HCPCS J1745 (Remicade / infliximab)
- AAPC — HCPCS Q5103 (Inflectra / infliximab-dyyb)
- AAPC — HCPCS Q5104 (Renflexis / infliximab-abda)
- AAPC — HCPCS Q5121 (Avsola / infliximab-axxq)
- AAPC — HCPCS Q5109 (Ixifi / infliximab-qbtx)
- FDA Remicade label (BLA 103772)
- Janssen CarePath — Remicade HCP resources
- Pfizer — Inflectra (Q5103) product information
- Organon — Renflexis (Q5104) product information
- Amgen Assist 360 — Avsola (Q5121) reimbursement guide
- UnitedHealthcare — Commercial Medical Drug policy database (infliximab)
- American College of Rheumatology — treatment guidelines (RA, AS, PsA)
- American Gastroenterological Association — IBD treatment guidelines
- American Academy of Dermatology — psoriasis treatment guidelines
- CMS — Medicare Part B Drug ASP Pricing File
- CMS — HCPCS quarterly update file
- CMS — JW / JZ modifier guidance
About this page
We maintain this page as a living reference for the entire infliximab family. Medicare ASP pricing for the four active HCPCS codes (J1745, Q5103, Q5104, Q5121) is bound to our underlying CareCost data layer and refreshes automatically when CMS publishes new quarterly files. Q5109 Ixifi has no current ASP (discontinued / limited supply). Coding and policy content is reviewed at least quarterly and updated whenever a manufacturer guide, FDA label, or major payer policy changes.
Found an error? Email hello@carecostestimate.com.
Refresh cadence
| Element | Cadence | How it's refreshed |
|---|---|---|
| Medicare ASP pricing (4 active codes) | Quarterly | Auto-bound to CareCost ASP layer; updates on CMS file release. |
| Payer policies (UHC, Aetna, Cigna, BCBS, PBM private-label) | Semi-annual | Manual review against published payer policy documents; biosimilar-mandate designations re-checked annually at year-start. |
| HCPCS / CPT / NCCI rules | Annual | Reviewed against CMS HCPCS quarterly files, AMA CPT releases, and NCCI edit updates. |
| NDC, dosing, FDA label | Event-driven | Tied to manufacturer document version + FDA label revision date for each of the five products. |
Reviewer
Pending SME review. This page is staff-authored from primary sources (FDA labels for all
five products, CMS, manufacturer billing PDFs from Janssen, Pfizer, Organon, and Amgen, payer policies,
and ACR / AGA / AAD clinical guidelines — all linked above). Editorial review in progress. Until that review is complete, treat this as a draft reference and verify
each cited source for high-stakes claims.
Change log
- — Initial publication of the five-product infliximab family reference. ASP data: Q2 2026 (J1745, Q5103, Q5104, Q5121; Q5109 unavailable). Payer policies: UnitedHealthcare biosimilar-mandatory, Aetna/Cigna lowest-cost-preferred, BCBS variable, PBM private-label biosimilars (CVS Cordavis, ESI Quallent, OptumRx Nuvaila). Indications per FDA: RA, AS, PsA, plaque psoriasis, Crohn's (adult + pediatric), UC (adult + pediatric).
Methodology
Every claim on this page is sourced inline. Pricing reflects the current CMS Part B Drug ASP Pricing File for the four active infliximab codes. Payer policies are read directly from each payer’s published medical policy documents. We do not paraphrase from billing-software vendor blogs. When manufacturer guidance and payer policy conflict, we surface the conflict rather than picking a side.