Entyvio — Medical Mutual

Initial criteria

• Patient age ≥ 18 years
• Patient has been receiving therapy with an immune checkpoint inhibitor (e.g., nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, cemiplimab, ipilimumab, tremelimumab, dostarlimab, retifanlimab, nivolumab/relatlimab, tislelizumab, toripalimab, etc.)
• Patient has mild (G1) diarrhea or colitis related to their immunotherapy with persistent or progressive symptoms and a positive lactoferrin/calprotectin OR patient has moderate (G2) to severe (G3-4) diarrhea or colitis related to their immunotherapy
• Site of care medical necessity is met

Reauthorization criteria

• Extended approval not recommended

Approval duration

3 doses over 6 weeks