Entyvio — Medical Mutual

Crohn’s Disease

Initial criteria

Patient is currently receiving Entyvio intravenous or will receive induction dosing with Entyvio intravenous within 2 months of initiating therapy with Entyvio subcutaneous
Patient age ≥ 18 years
Patient has tried at least one TNF blocker (e.g., Humira, Cimzia, or Remicade) or one immunomodulator for Crohn’s disease for at least 2 months, unless intolerant or has had an inadequate response with, was intolerant to, or demonstrated dependence on corticosteroids
Entyvio is prescribed by or in consultation with a gastroenterologist
Site of care medical necessity is met

Patient has responded (e.g., decreased stool frequency or rectal bleeding), as determined by the prescribing physician
Patient has been established on Entyvio subcutaneous or intravenous for at least 6 months

initial 6 months, reauth 12 months