These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Ustekinumab (Stelara) requires prior authorization from HealthPartners Pharmacy Administration.
Stelara is generally approved for use in patients diagnosed with moderate to severe psoriatic arthritis and plaque psoriasis when all the following criteria are met:
- Prescribed and followed by Dermatology or Gastroenterology.
- Patient has had a trial and failure of an appropriate regimen of first-line therapy based on the indication for treatment:
- Plaque psoriasis – First-line therapy including concurrent use of two of the regimens below for at least 3 months or intolerance or a contraindication to use:
- Topical corticosteroid therapy
- Phototherapy: at least 20-30 treatments given 2-3 times weekly Note: Home units are supported in certain situations (See the Home Phototherapy medical policy)
- Methotrexate 5mg-15mg weekly (GI intolerance requires trial of SC/IM methotrexate at 5mg-15mg weekly) in combination with folic acid supplementation
- Cyclosporine at a dose of at least 2.5 – 5 mg/kg/day until disease control achieved
- Acitretin at a dose of at least 25 mg daily
- Psoriatic Arthritis – First line therapy including concurrent use of the regimens below for at least 1 month:
- Continuous treatment with a NSAID at therapeutic doses; and,
- Methotrexate 20mg weekly (GI intolerance requires trial of SC/IM methotrexate at 20mg weekly)
- Crohn’s Disease – First line therapy including one of the following:
- Treatment with any of the following corticosteroid regimens for two weeks has been ineffective or is contraindicated:
- Prednisone 40-60 mg daily
- Oral budesonide 9 mg daily
- Budesonide rectal; or
- Inability to taper off one of the corticosteroid regimens above; or
- Breakthrough disease while stabilized for at least 3 months on one of the following therapies:
- Azathioprine 2-3 mg/kg daily
- 6-mercaptopurine 1-1.5 mg/kg daily
- Methotrexate 20mg weekly (GI intolerance requires trial of SC/IM methotrexate at 20mg weekly); and
- The prescribed regimen is within the FDA-approved dosing regimen. A current patient weight is required for all requests.
- When administered by a health-care professional as part of an assessment of disease activity. Requests for self-administration of Stelara will be reviewed for medical necessity
- No other biologic agent will be used concurrently to treat this indication.
Authorizations will be provided for one year with a limitation of a maximum of 5 procedures during the first year and 4 annually thereafter.
Reauthorizations for biologic regimens of up to FDA-approved doses and frequencies
Renewals will be provided annually with provider attestation that they have seen the patient within the last fourteen months and the patient is benefiting from use of the medication.
Requests for more intense (dose or interval) biologic therapy than the FDA-approved regimen
All requests for regimens exceeding the FDA-approved regimen (including annual renewals) will require provider attestation that the off-label regimen is medically necessary.
STELARA® is a human interleukin-12 and -23 antagonist indicated for the treatment of adult patients with:
- Moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy or,
- Active psoriatic arthritis alone or in combination with methotrexate.
- Moderately to severely active Crohn’s disease (CD) who have:
- failed or were intolerant to treatment with immunomodulators or corticosteroids, but never failed a tumor necrosis factor (TNF) blocker or
- failed or were intolerant to treatment with one or more TNF blockers.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
ustekinumab, for subcutaneous injection, 1 mg
ustekinumab, for intravenous injection, 1mg
Stelara 45 MG/0.5ML SOLN
Stelara 45 MG/0.5ML SOSY
Stelara 90 MG/ML SOSY
Stelara 130 MG/26ML SOLN
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- Stelara Full Prescribing Information; Janssen Biotech, Horsham, PA; Revised September 2016
- Menter A, Korman NJ, Elmets CA, et al., Guidelines of care for the management of psoriasis and psoriatic arthritis. J Am Acad Dermatol 2011;65:137-74.
- Hsu S, Papp KA, Lebwohl MG, et al., Consensus guidelines for the mangaement of plaque psoriasis. Arch Dermatol 2012 ;148 (1): 95-102.