CurrentUnitedHealthcarePolicy N/A

Zeposia (ozanimod) prior authorization

Prior authorization and reauthorization requirements for Zeposia (ozanimod) for UnitedHealthcare members, covering indications, duration of approval, and combination therapy restrictions affecting prescribers and pharmacy staff.

Policy Summary

PayerUnitedHealthcare

PolicyZeposia (ozanimod) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization (approvals issued for 12 months) and document positive clinical response for reauthorization; do not combine Zeposia with listed systemic targeted immunomodulators for the same indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

MS & UCindications

prohibitedcombination therapy

possibleautomated approval

Coverage Criteria for Zeposia (ozanimod)

Initial Authorization — Multiple Sclerosis

Policy Summary

PayerUnitedHealthcare

PolicyZeposia (ozanimod) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

SourceLink

On This Page

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Initial Therapy Criteria

Initial authorization rules differ by indication

MS initial: Diagnosis of multiple sclerosis

Authorization for 12 months

UC initial: Diagnosis of moderately to severely active ulcerative colitis AND not receiving Zeposia in combination with a systemic targeted immunomodulator for the same indication

Authorization for 12 months

Use of Zeposia in combination with a systemic targeted immunomodulator for treatment of the same indication is not allowed. Examples of systemic targeted immunomodulators listed in the policy include adalimumab, vedolizumab (Entyvio), mirikizumab-mrkz (Omvoh), upadacitinib (Rinvoq), golimumab (Simponi), risankizumab (Skyrizi), guselkumab (Tremfya), tofacitinib (Xeljanz/Xeljanz XR), and ustekinumab. Requests where the patient is receiving Zeposia in combination with one of these agents for the same indication may be denied or will not meet initial authorization or reauthorization criteria.

Provider Actions and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for Zeposia. Approvals are issued for 12 months for covered indications.

Initial and reauthorization criteria described in policy must be met before approval.
Authorization duration: 12 months.

Denial Risk

Combination Therapy Restriction

Initial and continuation (reauthorization) approvals require documentation of indication and restrictions on combination therapy. For initial use in ulcerative colitis, Zeposia is approved only when the patient has moderately to severely active disease and is not receiving Zeposia in combination with a systemic targeted immunomodulator for the same indication.

Ulcerative colitis initial criterion: moderately to severely active ulcerative colitis + no combination with systemic targeted immunomodulator.
Reauthorization requires documented positive clinical response and no combination therapy for same indication.
Examples of systemic targeted immunomodulators: adalimumab, vedolizumab, mirikizumab, upadacitinib, golimumab, risankizumab, guselkumab, tofacitinib, ustekinumab.

Documentation Required

Reauthorization Documentation

Reauthorization requires documentation of positive clinical response to therapy. Maintain and submit clinical evidence of benefit when requesting continuation.

Documentation should demonstrate objective or clinician-assessed improvement since initiation.
Reauthorization period: 12 months.

Step Therapy

Potential Step Therapy/Supply Limits

Supply limits and/or step therapy rules may apply. UnitedHealthcare may use prior claim/medication history, diagnosis codes, and automated processes to approve or reauthorize therapy.

Be prepared for supply limits or step therapy requirements that could affect initial approval or refill quantity.
Automated approval processes may use claims history and ICD-10 codes; prior authorization requirements still apply.

Key Definitions

Relapsing forms of MS

DefinitionIncludes clinically isolated syndrome, relapsing‑remitting disease, and active secondary progressive disease.

Indication contextZeposia (ozanimod) is indicated for treatment of relapsing forms of multiple sclerosis in adults.

Age groupAdults.

Moderately to severely active UC

DefinitionModerately to severely active ulcerative colitis as described in manufacturer labeling for adult patients.

Indication contextZeposia (ozanimod) is indicated for treatment of moderately to severely active ulcerative colitis in adults.

Age groupAdults.

Background

Ozanimod (Zeposia) is a sphingosine 1-phosphate receptor modulator approved for relapsing forms of multiple sclerosis and for moderately to severely active ulcerative colitis. Prior authorization is required and authorization decisions differ by indication: for ulcerative colitis, approval requires a diagnosis of moderately to severely active disease and that the patient is not receiving Zeposia in combination with a systemic targeted immunomodulator for the same indication. For ongoing therapy, reauthorization requires documentation of a positive clinical response to Zeposia and absence of concomitant use with a systemic targeted immunomodulator for the same indication. Approvals are generally issued for 12 months.

OpenPayer

Zeposia (ozanimod) prior authorization

Coverage Criteria for Zeposia (ozanimod)

Provider Actions and Authorization Rules

Key Definitions

Background

Reauthorization / Continuation Criteria

Step Therapy and Supply Limits