Q5109 Injection, ixifi, 10 mgInjection, infliximab-qbtx, biosimilar, (ixifi), 10 mg
14 of 15 payer prior-auth lists that name Q5109 require prior authorization or set conditions: Arkansas Blue Cross and Blue Shield, Blue Cross and Blue Shield of Texas, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of Ohio, Molina Healthcare of Utah.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Arkansas Blue Cross and Blue Shield | Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime) | AR | prior auth required | Non-preferred product | Apr 1, 2022 | Medical Benefit Pharmacy Prior Approval List |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 | |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 |
Q5109 appears in 13 coverage policies from Aetna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Wellmark Blue Cross Blue Shield.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Abatacept (Orencia) (0720) Rinvoq, Xeljanz, Otezla, Ruxolitinib, Hydroxychloroquine, Sulfasalazine | listed, no stance | Jul 1, 2026 | payer document |
| Aetna | Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments (0788) | not covered | Nov 19, 2025 | payer document |
| Aetna | Certolizumab Pegol (Cimzia) (0761) | listed, no stance | Jul 1, 2026 | payer document |
| Aetna | Diabetic Neuropathy: Selected Treatments (0729) Fulranumab, Ozone Therapy, Ghrelin, Interleukin - 6, mecobalamin (a vitamin B12 analog), pulsed magnetic field treatment | not covered | Feb 24, 2026 | payer document |
| Aetna | Dupuytren's Contracture Treatments (0800) Cryopreserved placental membrane, manugraphy | not covered | Nov 20, 2025 | payer document |
| Aetna | Golimumab (Simponi and Simponi Aria) (0790) | listed, no stance | Jul 31, 2026 | payer document |
| Aetna | Guselkumab (Tremfya) (1011) | listed, no stance | Jun 29, 2026 | payer document |
| Aetna | Natalizumab (0751) Plegridy, Aubagio, Gilenya, Tecfidera, Mavenclad and Mayzent | listed, no stance | Dec 2, 2025 | payer document |
| Aetna | Parkinson's Disease (0307) | listed, no stance | Feb 24, 2026 | payer document |
| Aetna | Risankizumab-rzaa (Skyrizi) (1009) | listed, no stance | Jul 1, 2026 | payer document |
| Aetna | Tildrakizumab-asmn (Ilumya) (1012) | listed, no stance | Jul 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Specialty Medication Administration Site of Care HCPCS Codes J0129, J0174, J0175, J0180, J0218, J0219, J0221, J0222, J0223, J0224, | listed, no stance | Jan 1, 2026 | payer document |
| Wellmark Blue Cross Blue Shield | Infliximab (05.01.05) | listed, no stance | Apr 1, 2026 | payer document |
Prior authorization required or conditional in IN.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.