Zymfentra — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• According to the prescriber, the patient is currently receiving infliximab intravenous maintenance therapy OR will receive induction dosing with an infliximab intravenous product within 3 months of initiating therapy with Zymfentra; AND
• Patient meets ONE of the following: (a) Patient had a trial of one systemic agent or was intolerant to one of these agents for ulcerative colitis; OR (b) Patient has pouchitis AND has tried therapy with an antibiotic, probiotic, corticosteroid enema, or mesalamine enema; AND
• The medication is prescribed by or in consultation with a gastroenterologist

Reauthorization criteria

• Patient has been established on infliximab product therapy for at least 6 months; AND
• Patient meets ONE of the following: (a) When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline; OR (b) Compared with baseline, patient experienced an improvement in at least one symptom such as decreased pain, fatigue, stool frequency, and/or rectal bleeding

Approval duration

initial 6 months; reauth 1 year