ustekinumab
This policy governs medical benefit coverage criteria for ustekinumab products (including biosimilars and specific brand names) for specified indications under UnitedHealthcare Individual Exchange plans (excludes MA, NV, NY). It affects prescribers, providers, and pharmacy/medical benefit adjudication for members of applicable plans.
Policy title changed from 'Stelara (Ustekinumab) Coverage Rationale' to 'ustekinumab'.
This policy now explicitly lists multiple ustekinumab products (Otulfi, Pyzchiva, Selarsdi, Stelara, Steqeyma, Wezlana, Yesintek) and states that FDA-approved ustekinumab biosimilars not listed will be considered non-preferred until reviewed.
Steqeyma (ustekinumab-stba) and Yesintek (ustekinumab-kfce) are designated as the preferred ustekinumab products; coverage for other non-preferred ustekinumab products is contingent on meeting Preferred Product Criteria and Diagnosis-Specific Criteria.
Steqeyma (ustekinumab-stba) and Yesintek (ustekinumab-kfce) are designated as the preferred ustekinumab products.
Coverage for non-preferred ustekinumab products (Otulfi, Pyzchiva, Selarsdi, Stelara, Wezlana, or other biosimilars) is contingent on meeting Preferred Product Criteria and Diagnosis‑Specific Criteria.
Members already on non-preferred ustekinumab products will be required to change therapy to Steqeyma or Yesintek unless they meet the Preferred Product Criteria for continuation.
Criteria allowing coverage of non-preferred ustekinumab include documented minimal response after at least 14 weeks of Steqeyma or Yesintek, provider attestation that clinical response would be superior with a non-preferred product, or documentation of intolerance/contraindication/adverse event to preferred products.
The list of targeted immunomodulators that must NOT be used in combination with ustekinumab was updated across diagnosis‑specific sections (additions and removals detailed per indication).
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