CareCost Prior authorization
Required
Check what the payer requires before you schedule Remicade.
Prior authorization · preferred product · clinical criteria · dosing · site of care
30 payer policy sets · source-linked · reviewed August 2026
Aetna + Crohn’s disease is shown as a live example until you choose a payer.
This payer requires an approval on file before Remicade is purchased or infused for this member.
Note : Requires Precertification: Precertification of an infliximab product is required of all Aetna participating providers and members in applicable plan designs.
Moderately to severely active Crohn's disease.
Crohn’s disease (CD) For treatment of moderately to severely active CD;
Induction: 5 mg/kg IV at weeks 0, 2, 6
Maintenance: 5 mg/kg IV every 8 weeks
Crohn's disease, moderate-to-severe or fistulizing (adults) Induction: 5 mg/kg IV at weeks 0, 2, and 6 Maintenance: 5 mg/kg IV every 8 weeks For persons who respond and then lose their response, consideration may be given to treatment with 10 mg/kg IV every 8 weeks. Persons who do not respond by week 14 are unlikely to respond and consideration should be given to discontinue infliximab in these persons.
What opens in CareCost
Aetna · Remicade · Crohn’s disease
For every requirement: the exact payer criteria, the source citation, a check-off, and a save to the patient’s chart.
In CareCost: check off each requirement · save to the patient · print for the chart
Aetna · Remicade · Crohn’s disease
You have already checked the policy, indication and covered dose. Open the remaining requirements and work them as a patient checklist.
CareCost tracks Remicade coverage requirements across 30 payer policy sets.
Aetna · Anthem / Elevance · Cigna · UnitedHealthcare · Regence · Premera · Kaiser · BCBS plans + more
Coverage clearance is only the first step.
CareCost carries the same patient through the entire workflow.
Finish this patient’s estimate →25 of 30 commercial payers require prior authorization. Prior-treatment, preferred-product and site-of-care rules vary by plan.
25 require PA · 30 have clinical criteria · 17 restrict site of care · 20 prefer a biosimilar
Many commercial payers require approval before infliximab is purchased or infused.
Coverage depends on the diagnosis included in the payer’s infliximab policy.
Plans may require documentation of previous therapies, failures, contraindications or preferred alternatives.
Some plans prefer a biosimilar or require an exception before covering Remicade.
The ordered dose and frequency may need to match diagnosis-specific policy criteria.
Some plans restrict specialty-drug infusions to approved sites or settings.
Certain diagnoses may require treatment by, or consultation with, a particular specialist.
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) |
No prior authorization for Part B infliximab. Coverage follows the diagnosis codes in the Medicare policy — the governing local coverage determinations are published in the CMS Medicare Coverage Database, and a MAC can differ from its neighbour on the same drug.
It depends on the payer and plan. Many commercial payers require prior authorization or apply clinical coverage criteria before treatment. Check this patient’s payer →
Clinical, dosing, product and site-of-care rules can still apply beyond the diagnosis. Crohn’s disease is a covered indication under many infliximab policies. Check coverage →
It depends on the payer. Some policies prefer another infliximab product or require an exception before Remicade is covered. Check preferred-product rules →
CareCost turns the applicable payer policy into a patient-level checklist showing each requirement, what to confirm, and the source language supporting it. Open patient clearance →
Data current: payer policies Aug 2026 · reviewed dates come from each payer
Payer medical and specialty-drug policies · prior-authorization criteria · site-of-care policies · preferred-product policies. Medicare coverage from the CMS Medicare Coverage Database. Every CareCost requirement links back to its source policy.