Entyvio — Medical Mutual

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, Remicade, or Simponi [subcutaneous]) or one immunomodulator for UC, 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

Reauthorization criteria

• 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

Approval duration

initial 6 months, reauth 12 months