CurrentCignaPolicy IP0691

Velsipity Prior Authorization Policy

Cigna coverage policy governing prior authorization requirements for Velsipity (etrasimod) for treatment of ulcerative colitis in adults under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyVelsipity Prior Authorization Policy

Policy CodePolicy IP0691

Change TypeNew policymaterial revisions to systemic trial requirements

Effective DateSep 1, 2025

Next Review Date

Key ActionObtain prior authorization: initial approvals for 6 months when patient is ≥18 and prescribed by or in consultation with a gastroenterologist; continuation approvals for 1 year when patient has been on therapy ≥6 months with documented benefit.

SourceLink

POLICY UPDATE CHANGES

New policy.

Clarified that a trial of a mesalamine product does not count as a systemic therapy for ulcerative colitis.

Removed the requirement that the patient has had a trial of one systemic agent for initial therapy for ulcerative colitis.

6 monthsinitial approval

1 yearestablished therapy

≥18min age

IP0691policy id

Coverage Criteria for Velsipity (etrasimod)

Policy Summary

PayerCigna

PolicyVelsipity Prior Authorization Policy

Policy CodePolicy IP0691

Change TypeNew policymaterial revisions to systemic trial requirements

Effective DateSep 1, 2025

Next Review Date

SourceLink

On This Page

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Ulcerative Colitis - Initial and Continuation Therapy

Velsipity is considered medically necessary when the following are met:

UC indication: Patient meets ONE of the following: A) Initial Therapy; OR B) Currently Receiving Velsipity.

A) Initial Therapy: Approve for 6 months if BOTH i and ii are met.6 months

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A.i: Patient is ≥ 18 years of age.

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A.ii: Medication is prescribed by or in consultation with a gastroenterologist.

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B) Currently Receiving Velsipity: Approve for 1 year if BOTH i and ii are met.1 year

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B.i: Patient has been established on therapy for at least 6 months.≥ 6 months on therapy

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B.ii: Patient meets at least ONE of the following: a) objective measure shows beneficial clinical response from baseline (examples: fecal calprotectin, C-reactive protein, endoscopy, reduced corticosteroid dose); OR b) improvement in at least one symptom versus baseline (examples: decreased pain, fatigue, stool frequency, rectal bleeding).

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Use of Velsipity (etrasimod) for any indication other than ulcerative colitis is considered not medically necessary.

Concurrent administration of Velsipity with another biologic or with a targeted synthetic oral small molecule drug used to treat inflammatory conditions is not covered. See the Appendix for examples of biologic agents and indications; combination therapy is generally not recommended because of a potentially higher rate of adverse events and lack of controlled clinical data supporting additive efficacy.

Concurrent combination therapy of Velsipity with another biologic, a targeted synthetic oral small molecule, or other potent immunosuppressants (for example, 6-mercaptopurine, azathioprine, cyclosporine, methotrexate) is considered not medically necessary due to safety concerns and absence of controlled data demonstrating added benefit.

Provider Requirements, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required before coverage. Approvals are provided for the durations specified in the policy (months = 30 days). Because of the specialized skills required for evaluation and monitoring, Velsipity must be prescribed by or in consultation with a physician who specializes in the condition being treated.

Prior authorization required before coverage
Approval durations per policy (months = 30 days)
Must be prescribed by or in consultation with a specialist (gastroenterologist for ulcerative colitis)

Prior Authorization

Preferred Product and Prior Trial Requirements

Refer to the Inflammatory Conditions Preferred Specialty Management Policies (PSM001, PSM002, PSM017) for preferred product and trial requirements. Note updates to trial language: a trial of a mesalamine product does not count as a systemic therapy for ulcerative colitis; the requirement for trial of one systemic agent for initial therapy has been removed where noted in the policy.

Preferred product requirements: see PSM001, PSM002, PSM017
Mesalamine does not count as a systemic therapy for ulcerative colitis
Requirement for trial of one systemic agent for initial therapy removed (see policy revisions)

Documentation Required

Continuation Therapy Documentation

For continuation/renewal requests, documentation must show the patient has been on Velsipity for at least 6 months and demonstrate benefit or tolerance as outlined in the continuation criteria.

Documentation of >= 6 months on therapy required for continuation approvals
Objective measures demonstrating benefit (e.g., fecal calprotectin, C-reactive protein, endoscopic assessment) or documented symptomatic improvement required

Documentation Required

Prescriber and Sample Documentation

Prescription must be by or in consultation with a gastroenterologist for ulcerative colitis. Receipt of sample product does not satisfy criteria or documentation requirements for coverage.

Prescriber requirement: by or in consultation with a specialist (gastroenterologist)
Samples do not satisfy criteria or documentation requirements

Denial Risk

Denial Triggers

Claims may be denied if billed without an applicable covered diagnosis or procedure code, for use in non-covered conditions, or when required documentation is missing or incomplete.

Denial triggers include: billing without covered diagnosis/procedure codes
Use for non-covered indications (see 'Conditions Not Covered')
Missing required documentation for initial or continuation approval

OpenPayer

Velsipity Prior Authorization Policy

Coverage Criteria for Velsipity (etrasimod)

Coding and Approval Durations

Provider Requirements, Documentation, and Denial Triggers

Background

Drug Definition