CommercialPrior AuthHigh impact
Mirikizumab-mrkz (Omvoh) (CPB 1048, reviewed 2026-07-01)
Aetna·Gastroenterology, Internal Medicine, Infectious Disease·Medical Policy
Effective date
Jul 1, 2026
We identified it
Aug 16, 2026
Summary
Aetna's new policy (CPB 1048, effective 2026-07-01) restricts coverage of mirikizumab-mrkz (Omvoh) for moderately to severely active Crohn's disease and ulcerative colitis to patients who have failed or cannot tolerate six specific alternative targeted immune modulators. Omvoh requires precertification and must be prescribed by or in consultation with a gastroenterologist. The policy establishes specific continuation criteria based on clinical response measures including disease activity scores and biomarkers.
Action Required
REQUIREMENTS - By 2026-07-01: (1) Billing team must implement precertification requirement in billing system for all Omvoh (J2267) claims - route all requests through Aetna precertification at (866) 752-7021 or fax (888) 267-3277 before claim submission. (2) Update billing software to flag Omvoh requests for gastroenterology validation - confirm prescriber is a gastroenterologist or is consulting with one before processing. (3) Providers must document that patient has failed all six alternative drugs (one-month trial each minimum): Entyvio, Skyrizi, Pyzchiva or Stelara, Tremfya, and Avsola/Inflectra/Renflexis, OR has documented contraindications/intolerances to each. Add documentation checklist to encounter templates. (4) For continuation claims (renewals), billing team must verify clinical response documentation is attached, including at least ONE of: remission status, disease activity scores (UCEIS/Mayo for UC; CDAI for CD), or biomarker improvement (CRP/fecal calprotectin for UC; hematocrit for CD). (5) Update billing templates to capture required baseline and follow-up measurements. Failure to obtain precertification or provide required documentation will result in claim denials.