Entyvio® (vedolizumab)

Authorization forms

Traditional, Optimized & Medicaid (09/2018)

 No prior authorization is required for Medicare

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J3380

Benefit: Medical

Notes: For treatment of adult Crohn's disease and ulcerative colitis