This version of the policy will become effective 05/05/2017.
This policy has been updated to communicate the coverage of vedolizumab (Entyvio®) when dosing and frequency requirements are met.
The time-frame of a 3-month trial was added to the Policy criteria for a tumor necrosis factor (TNF) blocker or immunomodulator.
Ustekinumab (Stelara®) was added as a first-line agent as an option for those not previously treated with a biologic to treat adult moderately to severely active ulcerative colitis or moderately to severely active Crohn's disease.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Policy: 08.00.34m:Infliximab and Related Biosimilars
Policy: 08.00.64f:Natalizumab (Tysabri®)
Policy: 08.00.82j:Ustekinumab (Stelara®)