Zeposia — Medical Mutual
Ulcerative Colitis – Patient is Currently Receiving Zeposia
Preferred products
- adalimumab-adaz
- adalimumab-adbm
- Cyltezo
- adalimumab-ryvk
- Simlandi
- Omvoh subcutaneous
- Skyrizi subcutaneous (on-body injector)
- ustekinumab-ttwe subcutaneous
- Yesintek subcutaneous
- Tremfya subcutaneous
- Velsipity
- Zymfentra
Initial criteria
- Patient meets the standard Multiple Sclerosis and Ulcerative Colitis – Zeposia Prior Authorization Policy criteria; AND
- Patient meets ONE of the following: a) Patient has tried TWO of an adalimumab product, Omvoh subcutaneous, Skyrizi subcutaneous, ustekinumab subcutaneous product, Selarsdi subcutaneous, ustekinumab-ttwe subcutaneous, Yesintek subcutaneous, Tremfya subcutaneous, Velsipity, and Zymfentra (trials of infliximab IV, Simponi SC, Entyvio IV or SC, Omvoh IV, Skyrizi IV, ustekinumab IV, Tremfya IV also count); OR b) Patient has been established on Zeposia ≥ 90 days and prescription claims history indicates ≥ 90-day supply dispensed within past 130 days [or prescriber verifies if claims unavailable, and received via paid claims]
Approval duration
1 year