Omvoh — CareFirst (Caremark)

moderately to severely active ulcerative colitis in adults

Initial criteria

Prescribed by or in consultation with a gastroenterologist
Member has moderately to severely active ulcerative colitis
Member has had a documented negative tuberculosis (TB) test (TST or IGRA) within 12 months prior to initiating therapy for persons naïve to biologic or targeted synthetic drugs associated with an increased risk of TB
If TB screening is positive, there is further testing confirming no active disease (e.g., chest x-ray)
Do not administer if active TB infection is present
If latent TB infection is present, TB treatment must be started before initiation
Medication will not be used concomitantly with any other biologic drug or targeted synthetic drug for the same indication

Member continues treatment of moderately to severely active ulcerative colitis and has achieved or maintained remission OR a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms with improvement from baseline in any of the following: stool frequency, rectal bleeding, urgency of defecation, C-reactive protein (CRP), fecal calprotectin (FC), appearance of the mucosa on endoscopy, computed tomography enterography (CTE), magnetic resonance enterography (MRE), or intestinal ultrasound, or improvement on a disease activity scoring tool (e.g., Ulcerative Colitis Endoscopic Index of Severity [UCEIS], Mayo score)

12 months