Velsipity (etrasimod tablets – Pfizer) — Cigna

Initial criteria

• Patient has a diagnosis of ulcerative colitis with moderately to severely active disease
• Patient age ≥ 18 years
• Medication is prescribed by or in consultation with a gastroenterologist

Reauthorization criteria

• Patient has been established on therapy for at least 6 months
• Patient experienced a beneficial clinical response from baseline as measured by at least one objective assessment (e.g., fecal calprotectin, C-reactive protein, endoscopic assessment, or reduced corticosteroid dose) OR patient experienced an improvement in at least one symptom (e.g., decreased pain, fatigue, stool frequency, decreased rectal bleeding)

Approval duration

initial 6 months; reauth 1 year