Entyvio subcutaneous — Medica
Ulcerative colitis
Preferred products
- Crohn’s disease: adalimumab-adaz, adalimumab-adbm, Cyltezo, adalimumab-ryvk, Simlandi, Omvoh subcutaneous, Skyrizi subcutaneous (on-body injector), Stelara subcutaneous, Rinvoq, Cimzia, Zymfentra
- Ulcerative colitis: adalimumab-adaz, adalimumab-adbm, Cyltezo, adalimumab-ryvk, Simlandi, Skyrizi subcutaneous (on-body injector), Stelara subcutaneous, Tremfya subcutaneous, Omvoh subcutaneous, Rinvoq, Simponi SC, Xeljanz/XR, Velsipity, Zymfentra
Initial criteria
- Patient meets the standard Inflammatory Conditions – Entyvio Subcutaneous Prior Authorization Policy criteria
- Patient meets ONE of the following: (a) Patient has Crohn’s disease and has tried TWO of adalimumab product, Omvoh subcutaneous, Skyrizi subcutaneous, Stelara subcutaneous, Zymfentra, Cimzia, or Rinvoq [documentation required]; OR (b) Patient has Ulcerative colitis and has tried TWO of adalimumab product, Skyrizi subcutaneous, Stelara subcutaneous, Tremfya subcutaneous, Zymfentra, Omvoh subcutaneous, Rinvoq, Simponi subcutaneous, Velsipity, or Xeljanz/XR [documentation required]; OR (c) According to the prescriber, the patient has been established on Entyvio intravenous for at least 90 days; OR (d) Patient has been established on Entyvio subcutaneous for at least 90 days and prescription claims history indicates at least a 90-day supply dispensed within the past 130 days [verification required as per criteria]
Approval duration
1 year