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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsWashington HCA Etrasimod Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentWashington State Health Care AuthorityPolicy 66.27.00.AK-6

    Cytokine and CAM Antagonists: S1-P Receptor Modulators

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    This policy governs prior authorization and medical-necessity coverage for etrasimod (Velsipity) for adults with moderate-to-severe ulcerative colitis, including authorization criteria, reauthorization, preferred-drug trials, dosing limits, and documentation requirements.

    Policy Summary
    PayerWashington State Health Care Authority
    PolicyCytokine and CAM Antagonists: S1-P Receptor Modulators
    Policy CodePolicy 66.27.00.AK-6
    Change TypeMaterial revision
    Effective DateJul 1, 2025
    Next Review DateNot specified
    Key ActionSubmit prior authorization for etrasimod (Velsipity) with documentation of required conventional and preferred-drug treatment history.
    SourceLink
    POLICY UPDATE CHANGES

    The policy added a requirement for trial and failure of two preferred Cytokine and CAM Apple Health Preferred Drug List medications.

    Zeposia was separated from this policy.

    1drug covered under the clinical criteria
    6 monthsinitial authorization period
    12 monthsreauthorization period when response criteria are met

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    30 tablets/30 days
    quantity limit for Velsipity 2 mg tablets
    2preferred medications required to have failed before initial authorization

    Coverage Criteria

    Initial Therapy

    Etrasimod (Velsipity) may be approved when all the following documented criteria are met. FDA-approved dosing and quantity limits: 2 mg once daily; 2 mg tablets, 30 tablets per 30 days.

    ALL of the following

    • Patient is 18 years of age or older.
    • Prescribed by, or in consultation with a gastroenterologist.
    • Not used in combination with another Cytokine and CAM medication.
    • Diagnosis of moderate-to-severe Ulcerative Colitis (UC).
    • Baseline assessments are included (e.g., stool frequency, endoscopy results, presence of rectal bleeding, disease activity scoring tool).
    • Treatment with conventional therapy (e.g., systemic corticosteroids, azathioprine, mesalamine, sulfasalazine) has been ineffective, unless all are contraindicated or not tolerated.minimum trial of 12 weeks
    • Treatment with two preferred Cytokine and CAM Apple Health Preferred Drug List (PDL) medications has each been ineffective, unless all are contraindicated or not tolerated.minimum trial of 12 weeks

    Reauthorization

    Etrasimod (Velsipity) may be approved for reauthorization when all the following documented criteria are met. If all criteria are met, the request will be authorized for 12 months.

    ALL of the following

    • Not used in combination with another Cytokine and CAM medication.
    • Documentation is submitted demonstrating disease stability or a positive clinical response (e.g., decreased stool frequency, decreased rectal bleeding, improvement in endoscopic activity, tapering or discontinuation of corticosteroid therapy, or improvement on a disease activity scoring tool).

    Velsipity is excluded from coverage when used in combination with another Cytokine and CAM medication. This exclusion applies to both initial therapy and reauthorization coverage.

    Coding

    Codingmixed
    N/AN/A

    Provider Actions and Authorization Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for etrasimod (Velsipity). Etrasimod may be medically necessary when the clinical-policy criteria are met; if criteria are not met, a clinical reviewer may determine medical necessity and approve the request on a case-by-case basis, including for a new FDA-approved indication.

    • New-to-market drugs in this class listed as non-preferred on the Apple Health Preferred Drug List (AHPDL) are subject to these prior authorization criteria.
    • Review the current AHPDL for preferred-agent status: https://www.hca.wa.gov/assets/billers-and-providers/applehealth-preferred-drug-list.xlsx
    Prior Authorization

    Authorization Duration

    When all initial clinical criteria are met, the request is authorized for 6 months. When all reauthorization criteria are met, continued therapy is authorized for 12 months.

    • Initial authorization: 6 months
    • Reauthorization: 12 months

    Clinical Background

    Ulcerative colitis is an inflammatory bowel disease. Patients with moderate-to-severe ulcerative colitis may require systemic corticosteroids, immunomodulatory therapies such as azathioprine, or biologic and other advanced therapies to induce and maintain remission. The policy requires documentation of baseline disease activity—such as stool frequency, endoscopy results, rectal bleeding, or a disease activity score—and evidence of treatment history before etrasimod authorization.

    Definitions

    Non-preferred agent
    DefinitionAn agent listed as non-preferred on the Apple Health Preferred Drug List (AHPDL).
    Preferred-agent requirementA non-preferred agent requires an inadequate response or documented intolerance due to a severe adverse reaction or contraindication to at least two preferred agents.
    Single-preferred-agent exceptionIf only one preferred agent exists in the class, documentation of inadequate response to that one preferred agent is required.
    Apple Health Preferred Drug List
    NameApple Health Preferred Drug List (AHPDL).
    PurposeIdentifies the current preferred and non-preferred drugs in this class.

    Initial Therapy Criteria

    Initial Therapy Criteria

    Etrasimod (Velsipity) may be approved when all documented initial-therapy criteria are met:

    ALL of the following

    • Patient is 18 years of age or older.>= 18 years
    • Etrasimod is prescribed by, or in consultation with, a gastroenterologist.
    • Etrasimod is not used in combination with another Cytokine and CAM medication.
    • Patient has a diagnosis of moderate-to-severe ulcerative colitis.

    Continuation Criteria

    Continuation Therapy Criteria

    Etrasimod (Velsipity) may be approved for reauthorization when all documented criteria are met:

    ALL of the following

    • Etrasimod is not used in combination with another Cytokine and CAM medication.
    • Documentation demonstrates disease stability or a positive clinical response, such as decreased stool frequency, decreased rectal bleeding, improvement in endoscopic activity, tapering or discontinuation of corticosteroid therapy, or improvement on a disease activity scoring tool.

    Step Therapy Sequence

    StepRequired therapyRequirement
    1Conventional therapy, such as systemic corticosteroids, azathioprine, mesalamine, or sulfasalazineMust be tried before etrasimod; minimum trial of 12 weeks unless all are contraindicated or not tolerated.
    StepPreferred-agent requirementRequirement for non-preferred therapy
    2Try two preferred Cytokine and CAM Apple Health Preferred Drug List medications; each requires a minimum 12-week trial.Each preferred agent must have been ineffective, contraindicated, or not tolerated. If only one preferred agent exists, that one agent must be tried.

    Quantity Limits

    Quantity Limit
    DrugVelsipity
    Strength and dosage form2 mg tablets
    Quantity limit30 tablets per 30 days
    Policy Summary
    PayerWashington State Health Care Authority
    PolicyCytokine and CAM Antagonists: S1-P Receptor Modulators
    Policy CodePolicy 66.27.00.AK-6
    Change TypeMaterial revision
    Effective DateJul 1, 2025
    Next Review DateNot specified
    Key ActionSubmit prior authorization for etrasimod (Velsipity) with documentation of required conventional and preferred-drug treatment history.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions and Authorization RequirementsClinical BackgroundDefinitionsInitial Therapy CriteriaContinuation CriteriaStep Therapy SequenceQuantity Limits
    Step Therapy

    Conventional Therapy Trial

    Before initial etrasimod authorization, document that treatment with conventional ulcerative-colitis therapy was ineffective, unless the therapies were contraindicated or not tolerated.

    • Minimum trial: 12 weeks
    • Examples include systemic corticosteroids, azathioprine, mesalamine, and sulfasalazine.
    Step Therapy

    Preferred-Drug Trial

    Document inadequate response to two preferred Cytokine and CAM medications on the Apple Health Preferred Drug List before requesting a non-preferred agent such as etrasimod, unless the preferred agents were contraindicated or not tolerated.

    • Each preferred-agent trial must generally be at least 12 weeks.
    • If only one preferred agent exists in the class, document inadequate response to that one agent.
    • For contraindication or intolerance, document the severe adverse reaction or the applicable contraindication.
    Documentation Required

    Initial Clinical Documentation

    Submit the initial clinical documentation needed to establish eligibility for etrasimod treatment for moderate-to-severe ulcerative colitis.

    • Patient is 18 years of age or older.
    • Etrasimod is prescribed by, or in consultation with, a gastroenterologist.
    • Document a diagnosis of moderate-to-severe ulcerative colitis.
    • Include baseline assessments, such as stool frequency, endoscopy results, rectal bleeding, and a disease-activity scoring tool.
    Documentation Required

    Reauthorization Response Documentation

    For reauthorization, submit documentation demonstrating disease stability or a positive clinical response to etrasimod.

    • Examples include decreased stool frequency, decreased rectal bleeding, improvement in endoscopic activity, tapering or discontinuation of corticosteroid therapy, or improvement on a disease-activity scoring tool.
    Denial Risk

    Failure to Meet Clinical Criteria

    Requests may not be authorized when the required initial or continuation criteria are not documented. A clinical reviewer may still determine medical necessity and approve a request on a case-by-case basis.

    • Initial requests require all applicable clinical criteria, including age, gastroenterology involvement, diagnosis, baseline assessment, conventional-therapy history, and preferred-agent history.
    • Reauthorization requires documented disease stability or positive clinical response.
    • The clinical reviewer may use reauthorization criteria when a patient is already established on therapy and is new to Apple Health.
    Documentation Required

    Insufficient Preferred-Agent History

    If the required history with preferred agents is unavailable or insufficient, document the reason and the relevant treatment history before requesting a non-preferred agent.

    • Non-preferred agents generally require inadequate response or documented intolerance due to a severe adverse reaction or contraindication to at least two preferred agents.
    • If only one preferred agent is available in the class, document inadequate response to that one preferred agent.
    • Document the duration and outcome of each trial; the minimum trial is generally 12 weeks unless contraindicated or not tolerated.
    • Confirm preferred-agent status using the current Apple Health Preferred Drug List.
    Denial Risk

    Combination Therapy Not Allowed

    Etrasimod may not be used in combination with another Cytokine and CAM medication. This restriction applies to both initial authorization and reauthorization.

    • Document that the patient is not receiving another medication in the Cytokine and CAM class.
    AccessThe current AHPDL is available through the Washington State Health Care Authority website.
    Baseline assessments are included, such as stool frequency, endoscopy results, presence of rectal bleeding, or a disease activity scoring tool.
  1. Treatment with conventional therapy, such as systemic corticosteroids, azathioprine, mesalamine, or sulfasalazine, has been ineffective, unless all are contraindicated or not tolerated.Minimum trial of 12 weeks
  2. Treatment with two preferred Cytokine and CAM Apple Health Preferred Drug List medications has each been ineffective, unless all are contraindicated or not tolerated.Minimum trial of 12 weeks for each medication