CurrentMass General Brigham Health PlanPolicy N/A

Velsipity (etrasimod) prior authorization — ulcerative colitis (pharmacy benefit)

Prior authorization policy for Velsipity (etrasimod) for treatment of moderately to severely active ulcerative colitis in adults under the commercial/exchange pharmacy benefit.

Policy Summary

PayerMass General Brigham Health Plan

PolicyVelsipity (etrasimod) prior authorization — ulcerative colitis (pharmacy benefit)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with required medical records demonstrating diagnosis and either prior therapy failure or documentation of disease severity; new-to-plan members must include evidence of current receipt of the drug.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial/ExchangePlan applicability

PharmacyBenefit type

24 monthsApproval duration

1/dayQuantity limit

Coverage Criteria for Velsipity (etrasimod)

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Initial Therapy

Authorization may be granted when ALL of the following are met:

Initial Authorization: Member has a diagnosis of moderately to severely active ulcerative colitis AND meets ONE of the therapy-related conditions below

Therapy requirement

Option A - prior therapy: Member has had trial and failure, intolerance, or contraindication to ONE of the following conventional therapies: 6-mercaptopurine; an aminosalicylate (e.g., mesalamine, olsalazine, sulfasalazine); azathioprine; or corticosteroids (e.g., prednisone).
Option B - disease severity: Disease severity warrants systemic biologic as first-line therapy.
This alternative allows bypass of conventional therapy requirement if systemic biologic is clinically indicated.

New-to-plan documentation: If member is new to the plan (coverage effective date ≤ 90 days), submission of medical records documenting current receipt of the requested drug (excluding samples or manufacturer patient assistance program supplies).

Continuation of Therapy

Requests for reauthorization will be approved when the following criteria are met:

Reauthorization: Submission of medical records (e.g., chart notes) demonstrating improvement in the member's condition, as evidenced by low disease activity or improvement in signs and symptoms of the condition.

This medication has a specialty designation and must be filled at a contracted specialty pharmacy under the plan's pharmacy benefit. Providers should ensure prescriptions for Velsipity (etrasimod) are routed to an in-network specialty pharmacy to avoid coverage disruption or denial.

Coding and Administrative Windows

New-to-plan documentation window — coverage effective date ≤ 90 days

DefinitionMember is considered new to the plan when the coverage effective date is less than or equal to 90 days.

Required documentation for new-to-plan membersSubmit medical records demonstrating the member is currently receiving the requested drug (excludes samples and manufacturer patient assistance program supplies).

PurposeEnsures continuity of therapy and verifies active treatment when member recently enrolled.

Provider Actions and Requirements

Prior Authorization

Prior authorization required for Commercial/Exchange pharmacy benefit

Prior authorization is required for Velsipity (etrasimod) under the pharmacy benefit for Commercial/Exchange members; authorization may be granted when the member meets the diagnosis-specific criteria for moderately to severely active ulcerative colitis.

Step Therapy

Trial of one conventional therapy required (unless systemic biologic warranted)

Authorization requires trial and failure, intolerance, or contraindication to ONE conventional therapy (6‑mercaptopurine; an aminosalicylate such as mesalamine, olsalazine, or sulfasalazine; azathioprine; or corticosteroids) unless disease severity warrants systemic biologic as first‑line therapy.

6‑mercaptopurine
Aminosalicylate (e.g., mesalamine, olsalazine, sulfasalazine)
Azathioprine
Corticosteroids (e.g., prednisone)

Documentation Required

Submit medical records for new-to-plan members and for reauthorization

If the member is new to the plan (coverage effective date ≤ 90 days), submit medical records documenting current receipt of the requested drug; for reauthorization submit medical records (e.g., chart notes) demonstrating improvement or low disease activity.

New-to-plan: documentation that member is currently receiving the requested drug (excluding samples or manufacturer patient assistance).
Reauthorization: chart notes showing improvement or low disease activity.

Denial Risk

Denial risk if required documentation or therapy trials are not shown

Requests may be denied if documentation does not demonstrate the member meets the diagnosis-specific criteria (including required new-to-plan documentation or the required trial/failure/intolerance/contraindication to a conventional therapy), or if reauthorization records do not show improvement/low disease activity.

Definitions

Moderately to severely active ulcerative colitis — Indication for etrasimod

IndicationModerately to severely active ulcerative colitis in adults (approved indication for etrasimod).

Policy requirementA diagnosis of moderately to severely active ulcerative colitis is required for coverage consideration of Velsipity (etrasimod).

Supporting guidancePolicy references professional guidelines and the Velsipity prescribing information for management of moderate to severe ulcerative colitis.