etrasimod — CareFirst (Caremark)

Initial criteria

• Member has a diagnosis of moderately to severely active ulcerative colitis
• Prescribed by or in consultation with a gastroenterologist
• Member is not using the requested medication concomitantly with immunomodulators, biologic drugs, or targeted synthetic drugs

Reauthorization criteria

• Member is using the requested medication for moderately to severely active ulcerative colitis
• Member achieves or maintains remission OR achieves or maintains a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition when there is improvement in any of the following from baseline: stool frequency, rectal bleeding, urgency of defecation, C-reactive protein (CRP), fecal calprotectin (FC), appearance of mucosa on endoscopy/CTE/MRE/ultrasound, or improvement on a disease activity scoring tool (e.g., UCEIS, Mayo score)

Approval duration

12 months