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Investigate Patient Insurance Benefits

Pfizer enCompass can research your patient’s insurance coverage details and payer requirements. Access Counselors are available to help patients and healthcare providers (HCPs):

  • Verify patient insurance benefits
  • Confirm prior authorization requirements
  • Assist with claims review and understanding appeal requirements, if necessary

Coverage Information

INFLECTRA has broad payer coverage. Coverage for INFLECTRA may vary from plan to plan within a payer, as well as across commercial payers, Medicare, and Medicaid, and by treatment site of care. HCPs should routinely verify patients’ insurance benefits and INFLECTRA coverage with each payer for confirmation.

Reimbursement, Coding, and Billing Overview

Pfizer enCompass has resources available on www.pfizerencompassonline.com to help HCPs understand the reimbursement process before and after treatment. Payers may recognize the following codes for reporting INFLECTRA on claim forms.

Effective for dates of service on or after April 1, 2018, CMS has assigned a new product-specific HCPCS Code for INFLECTRA. The previously assigned HCPCS code and manufacturer HCPCS modifier (Q5102 and modifier ZB) have been discontinued.

For reimbursement purposes, some payers may require the HCP to include the National Drug Code (NDC) on the claim form. For claims reporting purposes, HCPs may need to convert the 10-digit NDC to an 11-digit NDC by adding a “0” (zero) where appropriate to create a 5-4-2 configuration. The zero is added in front of the first segment of numbers when the 10-digit format is the 4-4-2 configuration. See placement of the underlined zero in the table below.

Product: INFLECTRA (infliximab-dyyb)

HCPCS Code2

Q5103: Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mg

National Drug Codes (NDCs)3

Strength

100 mg/20 mL

How Supplied

Single-use vial

10-digit NDC

0069-0809-01

11-digit NDC

00069-0809-01

2. Centers for Medicare & Medicaid Services. HCPCS release and code sets. HCPCS quarterly update. Other codes. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Downloads/Other-Codes-2018-April.zip. Accessed January 26, 2018.

3. INFLECTRA [package insert]. New York, NY: Pfizer Inc; 2017.

To assist with reimbursement, you may use the following resources.

Sample Letter of Medical Necessity for INFLECTRA Sample Letter of Appeal for INFLECTRA