CurrentColorado Rocky Mountain Health PlansPolicy 1 = 2025 P 1438-2

Velsipity (etrasimod) prior authorization

Defines prior authorization and reauthorization requirements for Velsipity (etrasimod) for treatment of moderately to severely active ulcerative colitis in adults; applies to UnitedHealthcare Pharmacy clinical pharmacy programs and members whose benefits include this drug.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyVelsipity (etrasimod) prior authorization

Policy CodePolicy 1 = 2025 P 1438-2

Change TypeNew programclarifications

Effective Date7/1/2025

Next Review Date

Key ActionObtain prior authorization by documenting diagnosis of moderately to severely active ulcerative colitis and that Velsipity is not used with a targeted immunomodulator.

SourceLink

POLICY UPDATE CHANGES

New program established for Prior Authorization/Notification for Velsipity (etrasimod).

Updated examples with no change to clinical intent; updated reference.

12 monthsauthorization duration

Adultsindicated population

Majority excludedcoverage exclusion

Apr 2024 & Apr 2025P&T approval

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inv-01: Initial Authorization

Velsipity will be approved based on both of the following criteria:

Initial Authorization

Diagnosis of moderately to severely active ulcerative colitis
Patient is not receiving Velsipity in combination with a targeted immunomodulator (examples: adalimumab; Cimzia [certolizumab]; Entyvio [vedolizumab]; Olumiant [baricitinib]; Omvoh [mirikizumab-mrkz]; Orencia [abatacept]; Rinvoq [upadacitinib]; Simponi [golimumab]; Skyrizi [risankizumab]; Tremfya [guselkumab]; ustekinumab; Xeljanz [tofacitinib])

inv-02: Reauthorization

Velsipity will be approved based on both of the following criteria:

Reauthorization

Documentation of positive clinical response to Velsipity therapy
Patient is not receiving Velsipity in combination with a targeted immunomodulator (examples: adalimumab; Cimzia [certolizumab]; Entyvio [vedolizumab]; Olumiant [baricitinib]; Omvoh [mirikizumab-mrkz]; Orencia [abatacept]; Rinvoq [upadacitinib]; Simponi [golimumab]; Skyrizi [risankizumab]; Tremfya [guselkumab]; ustekinumab; Xeljanz [tofacitinib])

Velsipity (etrasimod) is excluded from coverage for the majority of our benefits. This exclusion is stated at the program level and applies unless an explicit authorization rule or exception for a member’s benefit is identified.

Provider Actions, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required for Initial Therapy

Velsipity (initial authorization): Prior authorization required. Authorization will be issued for 12 months when ALL criteria are met.

Diagnosis: moderately to severely active ulcerative colitis
Must not be used in combination with a targeted immunomodulator (examples: adalimumab, certolizumab [Cimzia], vedolizumab [Entyvio], baricitinib [Olumiant], mirikizumab [Omvoh], abatacept [Orencia], upadacitinib [Rinvoq], golimumab [Simponi], risankizumab [Skyrizi], guselkumab [Tremfya], ustekinumab, tofacitinib [Xeljanz])
Authorization duration: 12 months

Documentation Required

Reauthorization Criteria — Documentation of Response Required

Reauthorization: Documentation and continuity requirements. Authorization will be issued for 12 months when ALL criteria are met.

Documentation of positive clinical response to Velsipity therapy is required
Patient must not be receiving Velsipity in combination with a targeted immunomodulator (same examples as initial criteria)
Authorization duration: 12 months
State mandates, federal regulatory requirements, and member benefit plan terms may affect coverage

Step Therapy

Step Therapy, Supply Limits, and Automated Approval

Step therapy, supply limits, exclusions, and automated approval logic that may affect coverage decisions.

Supply limits and/or step therapy may be in place
Velsipity is excluded from coverage for the majority of benefits (per source policy language) — verify member-specific benefit plan
UnitedHealthcare or the payer may approve initial or reauthorization based on prior claim/medication history, diagnosis codes (ICD‑10), and/or automated claim logic

Denial Risk

Denial Triggers

Conditions that may trigger denial of authorization.

Incorrect or unsupported diagnosis (not moderately to severely active ulcerative colitis)
Concurrent use of Velsipity with a targeted immunomodulator as listed above
Lack of documentation demonstrating positive clinical response at reauthorization
Member benefit exclusions or failure to meet step-therapy/supply limit requirements

Step	Requirement / Note
0	Supply limits and/or Step Therapy may be in place; specifics not provided in this policy.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyVelsipity (etrasimod) prior authorization

Policy CodePolicy 1 = 2025 P 1438-2

Change TypeNew programclarifications

Effective Date7/1/2025

Next Review Date

Key ActionObtain prior authorization by documenting diagnosis of moderately to severely active ulcerative colitis and that Velsipity is not used with a targeted immunomodulator.

SourceLink

On This Page

OpenPayer

Velsipity (etrasimod) prior authorization

Coverage Criteria for Velsipity (etrasimod)

Provider Actions, Documentation, and Denial Triggers

Background

Definitions

Initial Therapy

Continuation / Reauthorization Criteria

Step Therapy and Quantity Limits