CurrentCignaPolicy PSM004

Multiple Sclerosis and Ulcerative Colitis - Zeposia Preferred Specialty Management for Legacy Drug List Plans

Defines Cigna's preferred specialty management program coverage criteria for Zeposia (ozanimod) as a non-preferred product in legacy prescription drug list plans for indications of relapsing forms of multiple sclerosis and moderately to severely active ulcerative colitis, including required prior authorization, step therapy trials of preferred products, continuation criteria, and approval durations.

Policy Summary

PayerCigna

PolicyMultiple Sclerosis and Ulcerative Colitis - Zeposia Preferred Specialty Management for Legacy Drug List Plans

Policy CodePolicy PSM004

Change TypePreferred product list updates / annual revision

Effective Date01/01/2026

Next Review Date

Key ActionRequests for Zeposia require meeting the standard Multiple Sclerosis and Ulcerative Colitis - Zeposia Prior Authorization Policy criteria and Preferred Specialty Management program step/trial requirements; approvals are time-limited (6 months for UC initial therapy, 1 year for MS and continuation) as specified.

POLICY UPDATE CHANGES

New policy created (New policy).

Policy name changed and multiple Preferred product list updates across 2025 (additions/removals).

Annual revision specified adalimumab-ryvk NDCs starting with 82009 are Preferred and policy effective 01/01/2026.

2Indications covered (MS, UC)

1 yearTypical approval duration (continuation/MS)

6 monthsInitial UC approval duration

130 daysClaims history look-back

Coverage summary

Zeposia (ozanimod) is designated as a non-preferred product under the Inflammatory Conditions Preferred Specialty Management Program and requires prior authorization and step therapy trials of Preferred Products before approval of non-preferred products. The policy covers Zeposia for the indications of relapsing forms of multiple sclerosis and moderately to severely active ulcerative colitis in adults.

Quick facts and thresholds

Indications covered (MS, UC)Multiple sclerosis and moderately to severely active ulcerative colitis

Typical approval duration for continuation or MS1 year for continuation of therapy and for Multiple Sclerosis approvals

Initial Ulcerative Colitis approval duration6 months for UC initial therapy when exception criteria met

Claims history look-back period130 days (must show required 90- or 120-day use within 130-day look-back; prescriber verification if claims unavailable)

Initial therapy — Non-Preferred Product Exception Criteria

Non-Preferred Product Exception Criteria — Zeposia

Zeposia is a non-preferred product and is considered medically necessary only when non-preferred product exception criteria are met. The Inflammatory Conditions Preferred Specialty Management Program requires meeting the standard Prior Authorization Policy criteria and trials of Preferred Products when clinically appropriate.

1. General policy statement: Patient must meet the respective standard Multiple Sclerosis and Ulcerative Colitis - Zeposia Prior Authorization Policy criteria (see referenced prior authorization policy). Trials of Preferred Products are required prior to approval of Non-Preferred Products unless exception criteria below are met.

Continuation of therapy approvals for Non-Preferred or Preferred Products require verification noted as either verification in prescription claims history or verification by prescriber if claims history unavailable. All continuation approvals are for 1 year unless noted otherwise.

Continuation therapy

Non-Preferred Product Exception Criteria — Zeposia (continuation and verification rules)

Zeposia is medically necessary when the following exception criteria are met for the specified indication.

2. Ulcerative Colitis - Initial Therapy: Ulcerative Colitis - Initial Therapy

Approve for 6 months if criteria 2Ai and 2Aii are met; see 2B for alternative review when 2Aii not met.

2A: Approve for 6 months if the patient meets BOTH of the following (i and ii):6 months

i. Patient meets the standard Multiple Sclerosis and Ulcerative Colitis - Zeposia Prior Authorization Policy criteria. ii. Patient has tried TWO of the following preferred products: an adalimumab product, Omvoh subcutaneous, Skyrizi subcutaneous, ustekinumab subcutaneous product, Tremfya subcutaneous, Velsipity, and Zymfentra. Trials of certain IV formulations (e.g., infliximab IV products, Simponi SC, Entyvio IV/SC, Omvoh IV, Skyrizi IV, ustekinumab IV, Tremfya IV) also count per policy.

Unproven / exclusions

The policy states that Zeposia is considered medically necessary only when the Non-Preferred Product Exception Criteria are met; any other exception is considered not medically necessary. Approvals are therefore limited to the specified exception criteria and the standard prior authorization policy requirements — there is no blanket coverage of Zeposia without meeting those criteria.

Applicable codes / drug identifiers

Drug identifiers / NDC references mentionedNDC

00074	Humira NDCs starting with 00074 referenced as Preferred
82009	adalimumab-ryvk NDCs starting with 82009 referenced as Preferred
61314	Hyrimoz NDCs starting with 61314 (removed from Preferred per revision history)

What providers must do

Prior Authorization

Prior authorization required

Requests for Zeposia require meeting the standard Multiple Sclerosis and Ulcerative Colitis - Zeposia Prior Authorization Policy criteria and the Inflammatory Conditions Preferred Specialty Management Program step/trial requirements. Approvals are time-limited as specified in the policy: 6 months for Ulcerative Colitis initial therapy and 1 year for Multiple Sclerosis and for continuation approvals unless otherwise noted.

Documentation Required

Verification of prior therapy / claims history

For continuation approvals, verification of prior therapy is required. If at least 130 days of prescription claims history is available, claims must document the required prior use (e.g., a 90-day supply within the 130-day look-back). If 130 days of claims history is not available, the prescriber must verify the patient received the product for the specified duration (e.g., ≥90 days) and that the product was obtained via paid claims (no samples/coupons).

Clinical evidence and references

Reference: Zeposia capsules prescribing information, Celgene/Bristol Myers Squibb; August 2023. The policy cross-references the standard Multiple Sclerosis and Ulcerative Colitis - Zeposia Prior Authorization Policy criteria for approval and relies on the program's standard prior authorization requirements for MS and UC; the brief does not provide additional trial-level clinical metrics within the policy text.

Background

Background: Zeposia is a sphingosine 1-phosphate receptor modulator indicated for relapsing forms of multiple sclerosis and for moderately to severely active ulcerative colitis in adults. Under the Preferred Specialty Management Program the plan encourages use of designated Preferred Products and requires prior authorization and step therapy trials of Preferred Products before approving non-preferred products, with continuation and verification requirements as specified in the program.

Definitions / Program terms

Preferred ProductMedications designated by the Inflammatory Conditions Preferred Specialty Management Program that should be tried prior to Non-Preferred Products when clinically appropriate (e.g., adalimumab products, Omvoh SC, Skyrizi SC, ustekinumab SC products, Tremfya SC, Velsipity, Zymfentra)

Non-Preferred Product ExceptionCriteria under which a Non-Preferred Product (e.g., Zeposia) may be approved despite not being designated Preferred; requires meeting standard PA criteria and specific trials/verification per indication

Policy revision history

2024-12-01New policy

New policy created (New policy).

2025-01-01 to 2025-09-01Revised - Preferred product list updates and policy name change

Policy name changed and multiple Preferred product list updates across 2025 (additions/removals), including removal of Hyrimoz (NDCs starting with 61314) from Preferred; addition of Tremfya SC, addition of Velsipity, addition of Omvoh SC, and addition of Selarsdi, ustekinumab-ttwe, and Yesintek SC; adalimumab-adaz removed from Preferred.

2026-01-01Annual revisionLatest

Policy Summary

PayerCigna

PolicyMultiple Sclerosis and Ulcerative Colitis - Zeposia Preferred Specialty Management for Legacy Drug List Plans

Policy CodePolicy PSM004

Change TypePreferred product list updates / annual revision

Effective Date01/01/2026

Next Review Date

On This Page

2B - Alternate when 2Ai met but 2Aii not met: If patient meets standard Prior Authorization criteria (2Ai) but has not tried two preferred products (2Aii not met), a request for a Preferred Product may be reviewed using the respective standard Inflammatory Conditions Prior Authorization Policy criteria (list of Preferred Products provided in policy).

Preferred Product review options include specified adalimumab and ustekinumab products and other listed preferred agents.

3. Ulcerative Colitis - Patient Currently Receiving Zeposia: Criteria for patients currently receiving Zeposia

Approve for 1 year if both 3Ai and 3Aii are met; see 3B for alternative when 3Aii not met.

3A: Approve for 1 year if the patient meets BOTH of the following (i and ii):1 year

i. Patient meets the standard Multiple Sclerosis and Ulcerative Colitis - Zeposia Prior Authorization Policy criteria.

3Aii - ONE of: Patient meets ONE of the following conditions (a or b):

a) Patient has tried TWO of the listed preferred products (adalimumab products, Omvoh SC, Skyrizi SC, ustekinumab SC products, Tremfya SC, Velsipity, Zymfentra). Trials of listed IV/SC alternatives also count. b) Patient has been established on Zeposia for at least 90 days AND prescription claims history indicates at least a 90-day supply of Zeposia was dispensed within the past 130 days [verification in prescription claims history required]; if claims history is not available, prescriber verification is required that patient has been receiving Zeposia for at least 90 days AND via paid claims (no samples/coupons).

3B - Alternate when 3Aii not met: If the patient has met criterion 3Ai but not 3Aii, a request for a Preferred Product may be reviewed using the respective standard Inflammatory Conditions Prior Authorization Policy criteria.

Preferred Product review options include specified adalimumab and ustekinumab products and other listed preferred agents.

Step Therapy

Step therapy: required trials of Preferred Products

Ulcerative Colitis initial therapy requires trials of TWO Preferred Products prior to approval of the non-preferred product Zeposia unless specified exception criteria are met. The policy provides a list of Preferred Products (Preferred Step 1 products) that satisfy this requirement; see the policy for the enumerated Preferred Products.

Annual Revision dated 01/01/2026 specified adalimumab-ryvk NDCs starting with 82009 are Preferred and policy effective 01/01/2026.