Omvoh (mirikizumab-mrkz) — United Healthcare

moderately to severely active ulcerative colitis

Initial criteria

Diagnosis of moderately to severely active ulcerative colitis
AND one of the following:
Patient has been established on therapy with Omvoh under an active UnitedHealthcare medical benefit prior authorization for moderately to severely active ulcerative colitis
OR BOTH of the following:
Patient is currently on Omvoh therapy for moderately to severely active ulcerative colitis as documented by claims history or submission of medical records (document date and duration of therapy)
AND Patient has not received a manufacturer supplied sample at no cost in the prescriber’s office, or any form of assistance from an Eli Lilly sponsored program (e.g., sample card which can be redeemed at a pharmacy for a free supply of medication) as a means to establish as a current user of Omvoh
AND Patient is not receiving Omvoh in combination with another targeted immunomodulator [e.g., adalimumab, Cimzia (certolizumab), Enbrel (etanercept), Entyvio (vedolizumab), Olumiant (baricitinib), Orencia (abatacept), Rinvoq (upadacitinib), Simponi (golimumab), Skyrizi (risankizumab), ustekinumab, Tremfya (guselkumab), Xeljanz/Xeljanz XR (tofacitinib), Zeposia (ozanimod)]
AND Prescribed by or in consultation with a gastroenterologist

Documentation of positive clinical response to Omvoh therapy
AND Patient is not receiving Omvoh in combination with another targeted immunomodulator [e.g., adalimumab, Cimzia (certolizumab), Enbrel (etanercept), Entyvio (vedolizumab), Olumiant (baricitinib), Orencia (abatacept), Rinvoq (upadacitinib), Simponi (golimumab), Skyrizi (risankizumab), ustekinumab, Tremfya (guselkumab), Xeljanz/Xeljanz XR (tofacitinib), Zeposia (ozanimod)]

12 months