Entyvio subcutaneous — Cigna

Initial criteria

• Patient meets the standard Inflammatory Conditions – Entyvio Subcutaneous Prior Authorization Policy criteria.
• Patient meets ONE of the following: (a) For Crohn’s Disease, patient has tried TWO of an adalimumab product, Omvoh subcutaneous, Skyrizi subcutaneous, Tremfya subcutaneous, an ustekinumab subcutaneous product, Zymfentra, Cimzia, or Rinvoq; OR (b) for Ulcerative Colitis, patient has tried TWO of an adalimumab product, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Tremfya subcutaneous, Zymfentra, Omvoh subcutaneous, Rinvoq, Simponi subcutaneous, Velsipity, or Xeljanz/XR; OR (c) patient has been established on Entyvio intravenous for ≥ 90 days; OR (d) patient has been established on Entyvio subcutaneous for ≥ 90 days with prescription verification as specified.

Approval duration

1 year