Entyvio — Medical Mutual

Initial criteria

• 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

• Approve for an additional 12 months of therapy if the patient has responded (e.g., decreased stool frequency or rectal bleeding), as determined by the prescribing physician. Patient may not have a full response by Week 14, but there should be some response. Therapy should be discontinued in patients who show no benefit by Week 14

Approval duration

14 weeks initial, 12 months reauth