Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Mirikizumab-mrkz (Omvoh) IV may be considered medically necessary when an individual meets the following criteria:
Ulcerative Colitis
-
The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route);
and
- The individual must have failed a three (3)-month trial of a TNF inhibitor (infliximab, adalimumab, or golimumab), vedolizumab, AND ustekinumab, as evidenced by paid claims or pharmacy printouts.
If approved, mirikizumab-mrkz (Omvoh) IV will be allowed as three (3) intravenous infusions over eight (8) weeks.
Mirikizumab-mrkz (Omvoh) IV for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
