Prior Authorization : Preferred Drug List

Ulcerative Colitis

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

PA is required for non-preferred drugs.

Velsipity and Zeposia

Velsipity and Zeposia for members with ulcerative colitis require clinical PA.

Note: Zeposia is also a non-preferred drug in the MS agents drug class. PA requests for Zeposia, as a non-preferred MS agent, must be submitted with the Prior Authorization Drug Attachment for MS Agents form.

PA requests for Velsipity or Zeposia for members with ulcerative colitis must be completed, signed, and dated by the prescriber. PA requests for Velsipity or Zeposia for members with ulcerative colitis must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form. Clinical documentation supporting the use of Velsipity or Zeposia must be submitted with the PA request.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for Velsipity or Zeposia for members with ulcerative colitis may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

For information about general ForwardHealth PA policy for drugs that require PA approval, prescribers and pharmacy providers may refer to the Standard Pharmacy Policy for Covered and Noncovered Drugs topic. Providers may also refer to this topic for information about what may not be considered criteria to support the need for a drug.

Clinical Criteria for Velsipity and Zeposia for Members With Ulcerative Colitis

Clinical criteria that must be documented for approval of a PA request for Velsipity or Zeposia for members with ulcerative colitis are all of the following:

• The member has moderate to severe ulcerative colitis.
• The prescription is written by a gastroenterologist or through a gastroenterology consultation.
• The member has taken Humira for at least three consecutive months and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The member has taken Xeljanz for at least three consecutive months and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.

Supporting clinical information and a copy of the member's current medical records must be submitted with all PA requests for Velsipity or Zeposia for members with ulcerative colitis. The supporting clinical information and medical records must document the following:

• The member's medical condition being treated
• Details regarding previous medication use
• The member's current treatment plan

If the clinical criteria for Velsipity or Zeposia for members with ulcerative colitis are met, initial PA requests may be approved for up to 183 days.

Renewal PA requests for Velsipity or Zeposia for members with ulcerative colitis may be approved for up to 365 days. Renewal PA requests for members who have ulcerative colitis must include supporting clinical information and copies of the member's current medical records demonstrating that the member had a significant reduction in symptoms compared to the member's baseline prior to the initiation of the non-preferred drug.

All renewal PA requests require the member to be adherent with the prescribed treatment regimen.