Viva Health ustekinumab Prior Auth & Coverage

Coverage Criteria

Initial Therapy — Covered when ALL of the following are met (universal criteria plus indication-specific criteria).

Covered when ALL of the following are met (universal criteria plus indication-specific criteria):

Universal Requirements: Member meets age requirements; provider confirms up-to-date vaccinations; latent TB screening completed prior to initiation and ongoing monitoring planned; no active infection; no concurrent biologic/targeted synthetic therapy; prior exposure/contraindication/intolerance/failure to Selarsdi™, Stelara®, Ustekinumab, AND Yesintek™ documented as applicable.

From Universal and initial sections

Plaque Psoriasis (PsO): Member >= 6 years; baseline disease severity assessed with objective tool; documented moderate-to-severe plaque psoriasis ≥6 months with at least one of: ≥3% BSA involvement OR PASI ≥10 OR incapacitating location/intractable pruritus; and failed or is not a candidate for topical therapy (≥4 weeks), at least one non-biologic systemic agent (≥3 months), and phototherapy (≥3 months) unless already established on biologic/targeted therapy or >10% BSA.

Chunk 5

Adult Psoriatic Arthritis (PsA): Baseline severity assessed; documented moderate-to-severe active disease; AND either failure of a ≥4-week trial of an NSAID for axial/enthesitis phenotype OR failure of a ≥3-month trial of a csDMARD for peripheral/dactylitic phenotype OR already established on biologic/targeted therapy.

Chunk 6

Juvenile Psoriatic Arthritis (JPsA): Member ≥6 years; baseline severity assessed; documented moderate-to-severe polyarticular disease; may be used alone or with methotrexate; and either failed a ≥1-month trial of NSAID or csDMARD unless contraindicated OR already established on biologic/targeted therapy.

Chunk 7

Adult Crohn's Disease (CD): Baseline severity assessed; documented moderate-to-severe active disease; AND either failure/contraindication/ineffective response to a ≥3-month trial of corticosteroids or immunomodulators OR failure/contraindication/ineffective response to a ≥3-month trial of a TNF modifier OR evidence of high-risk disease requiring biologic therapy OR already established on biologic/targeted therapy.

Chunk 8

Pediatric Crohn's Disease (CD): Member ≥2 years; baseline severity assessed; documented moderate-to-severe active disease; AND either failure/contraindication/ineffective response to a ≥3-month trial of corticosteroids or immunomodulators OR failure/contraindication/ineffective response to a ≥3-month trial of a TNF modifier OR evidence of high-risk disease requiring biologic therapy OR already established on biologic/targeted therapy.

Chunk 9

Ulcerative Colitis (UC): Baseline severity assessed; documented moderate-to-severe active disease; AND either failure/ineffective response to a ≥3-month trial of conventional therapy (aminosalicylates, corticosteroids, immunomodulators) OR failure/contraindication/ineffective response to a ≥3-month trial of a TNF modifier OR already established on biologic/targeted therapy.

Chunk 10

Immune Checkpoint Inhibitor-Related Toxicities: Member receiving immune checkpoint inhibitor therapy with diarrhea/colitis refractory to infliximab and/or vedolizumab; includes persistent lactoferrin/calprotectin positive mild (G1) disease or moderate (G2) to severe (G3-4) disease.

Chunk 11

Supportive therapy with marnetegragene autotemcel: Member scheduled for marnetegragene autotemcel for severe LAD-I and therapy intended to prevent hyperinflammatory bone marrow microenvironment; limited to up to 3 total doses as specified in initial authorization limits.

Chunk 12

Continuation/Renewal Therapy — Renewal provided when ALL of the following are met.

Renewal provided when ALL of the following are met:

General Renewal: Member continues to meet universal and indication-specific criteria; duration of authorization has not been exceeded; absence of unacceptable toxicity (e.g., serious infections, malignancy, severe hypersensitivity, PRES/RPLS, non-infectious pneumonia).

Chunk 14

Plaque Psoriasis Renewal Response: Demonstrated disease response vs baseline such as improvement in redness/thickness/scaliness and/or total BSA involvement ≤1%, and/or PASI ≤3 or PGA ≤1.

Chunk 15

Adult PsA Renewal Response: Demonstrated improvement in tender/swollen joint counts, CRP, patient global assessment, imaging, or validated disease activity tool.

Chunk 16

JPsA Renewal Response:

Crohn's Disease Dosing (Induction and Maintenance)

Weight-tiered induction and maintenance dosing as specified below.

IV induction dosing by weight: Adult IV induction dose: ≤55 kg: 260 mg; >55 to 85 kg: 390 mg; >85 kg: 520 mg (one-time IV induction).weight tiers

Chunks 22-23

Maintenance dosing: Adult subcutaneous maintenance: 90 mg given 8 weeks after the initial IV dose, then every 8 weeks thereafter.every 8 weeks

Chunk 22

Pediatric induction and maintenance dosing: Pediatric IV induction and SC maintenance dosing specified by weight tiers (e.g., IV induction: 10 kg–25 kg: 10 mg/kg; >25–55 kg: 260 mg; >55–85 kg: 390 mg; >85 kg: 520 mg; Pediatric SC maintenance: 10–35 kg: 2.5 mg/kg given 8 weeks after IV induction then every 8 weeks, with other weight tiers as listed).

Plaque Psoriasis and Psoriatic Arthritis Dosing

Loading and maintenance subcutaneous dosing by weight and indication.

Adult plaque psoriasis loading: ≤100 kg: 45 mg at weeks 0 and 4 then begin maintenance 12 weeks later; >100 kg: 90 mg at weeks 0 and 4 then begin maintenance 12 weeks later.weight

Chunk 21

Adult plaque psoriasis maintenance: ≤100 kg: 45 mg every 12 weeks; >100 kg: 90 mg every 12 weeks.every 12 weeks

Chunk 21

Pediatric plaque psoriasis dosing: <60 kg: 0.75 mg/kg at weeks 0 and 4 then maintenance every 12 weeks; 60–100 kg: 45 mg loading and maintenance; >100 kg: 90 mg loading and maintenance.weight

Dose Escalation Criteria for Crohn's Disease & Ulcerative Colitis

Escalation allowed on case-by-case review when ALL conditions met and within specified limits.

Required conditions for escalation: Member has shown initial response to therapy; received the initial IV loading dose; received at least one subcutaneous maintenance dose; responded by treatment week 16 with subsequent loss of response.all conditions must be met

Chunk 24

Escalation limits: Dose escalation must not exceed 90 mg subcutaneously every 4 weeks; certain members may benefit from smaller interval reductions (e.g., symptomatic at 5–7 weeks).max 90 mg q4w

Chunk 24

Trough-guided adjustments: If ustekinumab trough (if available) is <4.5 µg/mL, candidate to decrease interval from 8 weeks to as frequently as 4 weeks and possibly consider one additional IV loading dose; if trough >4.5 µg/mL, may consider increasing interval to every 6 weeks with reassessment at 3 months; requests prior to week 16 evaluated case-by-case with clinical justification.

Supporting references and administrative criteria

Supporting materials and codes associated with medical necessity determinations for subcutaneous biologic therapy:

References: Multiple clinical guidelines and trials (psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis) are cited to support indications and dosing considerations.

Chunks 36-50 and citations section summarized in Appendix

Administrative inputs: NQTL factor checklist considered (PA applied for indication and cost reasons); ICD-10 diagnosis codes must be supplied to support medical necessity determinations.

Chunks 51-53

Diagnosis-based coverage

Covered when the patient's diagnosis matches one of the listed ICD-10 codes for the appropriate route (subcutaneous or intravenous).

Diagnosis match: Patient has a diagnosis code listed in the document appropriate to the requested route of administration (subcutaneous vs intravenous).ICD-10 code from lists

Lists are route-specific; see Subcutaneous (chunks 52-60) and Intravenous (chunk 61) sections for codes

Coverage excludes members with active infections and those receiving concurrent biologic or targeted synthetic therapies; these are universal screening and exclusion conditions that must be verified before initiation. Phototherapy is an expected step prior to biologic therapy for some dermatologic indications unless contraindicated — the policy lists examples of contraindications to PUVA/UVB phototherapy including xeroderma pigmentosum, pregnancy for PUVA, photosensitizing medications, severe liver/renal/cardiac disease, certain genetic photosensitivity syndromes, prior skin cancer or extensive solar damage, and specific anatomic ineligibility (face, genital, scalp, nail). Members who lack access to phototherapy may be reviewed on a case-by-case basis.

If a member undergoes dose escalation and does not regain clinical response within a 4-week interval after the shortened dosing interval, the policy states therapy should be discontinued. Prior authorization for escalation is initially provided for 3 months and continued approval requires documentation of clinical improvement (and trough levels if available).

The cited sections do not list additional explicit clinical exclusion criteria beyond the universal requirements and contraindications summarized elsewhere; utilization management considerations and the NQTL factor checklist are provided to explain why prior authorization is applied.

Medicare coverage rules may differ from the non‑Medicare policy content. The document directs reviewers to consult the CMS Medicare Benefit Policy Manual and the Medicare Coverage Database for any applicable NCD, LCD, or LCA when making coverage determinations for Part B drugs.

Initial prior authorization periods are specified by indication (generally 6 months (180 days) for most starts, 8 weeks for Crohn's Disease and Ulcerative Colitis induction, and indication‑specific limits for immune checkpoint inhibitor toxicities or supportive Kresladi use). Renewal authorizations are typically available for 12 months (365 days) when renewal criteria are met. Dose‑escalation authorizations for Crohn's/UC are initially granted for 3 months (90 days) with subsequent 12‑month renewals contingent on documented clinical improvement and drug levels if available.

These chunks do not present standalone 'not medically necessary' statements for specific clinical scenarios beyond the examples where renewal is restricted (for example, certain ICI‑related dosing and supportive Kresladi use may not be renewed). Requests that exceed the documented authorization durations or lack required supporting documentation may be considered not medically necessary per the policy's renewal rules.

There is no explicit 'not medically necessary' list for Medicare members in the cited text; instead, the policy emphasizes that Medicare Part B coverage determinations are governed by applicable NCDs, LCDs, and LCAs and that compliance with those CMS documents is required where applicable. The NQTL appendix and CMS guidance should be consulted when processing Medicare claims.

Initial Therapy Criteria (Indication-specific)

Initial therapy — Indication-specific initial requirements.

Indication-specific initial requirements:

Initial general: Member meets universal screening and vaccination/TB requirements; provider documents prior therapy failures, contraindications, or intolerance as indicated for the specific diagnosis; age criteria met per indication.

Chunks 3-4 and indication specifics

Psoriasis initial specifics: For Plaque Psoriasis: member ≥6 years, objective baseline severity, ≥6 months disease, and failed topical (≥4 weeks), at least one non-biologic systemic (≥3 months), and phototherapy (≥3 months) unless exceptions apply.

Chunk 5

PsA initial specifics: For Adult PsA: baseline assessment and either NSAID trial failure (≥4 weeks) for axial/enthesitis or csDMARD trial failure (≥3 months) for peripheral/dactylitis phenotype, or already on biologic/targeted therapy.

Continuation and Renewal Criteria

Continuation therapy rules — Renewal/continuation rules and limits.

Renewal/continuation rules and limits

Standard Renewal: Renewal may be granted for 12 months (365 days) if renewal criteria are met; dose escalation authorizations for Crohn's/UC initially provided for 3 months (90 days) with subsequent 12-month renewals; some indications (e.g., ICI-related toxicities, supportive Kresladi use) may not be renewed.

Chunks 1,2,14

Continuation after response — Ongoing therapy after initial response.

Ongoing therapy after initial response

Continuation after response: Members who are responding may continue current dosing; prior authorization validity for escalation is provided for 3 months with continued approval contingent upon demonstration of clinical improvement and ustekinumab levels (if available). Members who do not regain response at a 4-week escalated interval should discontinue therapy.

Chunk 24

Step Therapy Requirements

Indication	Required prior therapy / minimum trial	Notes
Plaque Psoriasis (PsO)	Topical agents: minimum 4-week trial; AND at least ONE non-biologic systemic agent: minimum 3-month trial; AND phototherapy (PUVA or UVB): minimum 3-month trial	Trials not required for members already established on biologic/targeted therapy or with >10% BSA involvement; member must meet age and severity criteria (see policy).
Adult Psoriatic Arthritis (PsA)	Axial disease/enthesitis: NSAID trial ≥4 weeks; OR peripheral arthritis/dactylitis: csDMARD trial ≥3 months	If already established on biologic/targeted therapy, prior NSAID/csDMARD trial may be waived; baseline severity assessment required.
Adult Crohn's Disease (CD)	Corticosteroids or immunomodulators (e.g., azathioprine, 6‑mercaptopurine, methotrexate): minimum 3-month trial OR TNF modifier: minimum 3-month trial	Three months of corticosteroids not required if early non-response is confirmed; exceptions for contraindication or established biologic therapy apply.
Pediatric Crohn's Disease (CD)	Corticosteroids or immunomodulators: minimum 3-month trial OR TNF modifier: minimum 3-month trial	Applies to pediatric members (≥2 years); same exceptions for early non-response or contraindication as adult CD.
Ulcerative Colitis (UC)	Conventional therapy (aminosalicylates, corticosteroids, immunomodulators) at maximum tolerated doses: minimum 3-month trial OR TNF modifier: minimum 3-month trial	Three-month corticosteroid requirement may be waived for early non-response; exceptions for contraindication or established biologic therapy apply.

Requirement	Documentation needed	Coverage implication
Initial response demonstrated before escalation	Clinical evidence of initial response by treatment week 16 (or clinical justification for earlier escalation)	Dose escalation considered only if initial response documented; prior authorization for escalation provided short-term (3 months) pending improvement.
[{"text":"Receipt of specified IV induction dose","status":""},{"text":"Record of weight-tiered IV induction dosing as specified in policy (e.g., ≤55 kg 260 mg; >55–85 kg 390 mg; >85 kg 520 mg)","status":""},{"text":"Required prior to considering subcutaneous dose escalation for CD/UC.
status":""}]
At least one subcutaneous maintenance dose administered	Documentation that member received minimum one SC maintenance dose following IV induction (per dosing schedule)	Required step before escalation; supports assessment of loss of response on standard maintenance interval.
Ustekinumab trough level (if available) to guide escalation	Trough <4.5 μg/mL supports interval shortening to as frequently as every 4 weeks; trough >4.5 μg/mL may support interval lengthening to every 6 weeks with reassessment	Trough levels (if covered) may be required to justify escalation or interval changes; continued approval contingent on documented clinical improvement and levels.
Maximum escalation limits	Dose escalation must not exceed 90 mg SC every 4 weeks; some members may benefit from smaller interval reductions (e.g., 5–7 weeks)	Requests exceeding these limits are not permitted; members who do not regain response at 4-week escalated interval should discontinue therapy.

Policy statement	Implication	Citation
Additional indications may be applied at the discretion of the health plan	Plan may extend coverage to other indications not explicitly listed in criteria; provider should consult plan policy and PA process	Appendix note: additional indications possible at plan discretion; Medicare NCD/LCD/LCA compliance required where applicable.

Coding

HCPCS CodesHCPCS

J3357	Ustekinumab, for subcutaneous injection, 1 mg; 1 billable unit = 1 mg (Stelara SQ Only; Includes unbranded biologic §)
J3358	Ustekinumab, for intravenous injection, 1 mg; 1 billable unit = 1 mg (Stelara IV Only; Includes unbranded biologic §)
J3590	Unclassified biologics (Discontinue use on 07/01/2026)
C9399	Unclassified drugs or biologicals (Discontinue use on 07/01/2026)
Q5137	Injection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg; 1 billable unit = 1 mg
Q5138	Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg; 1 billable unit = 1 mg
Q9996	Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg; 1 billable unit = 1 mg
Q9997	Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg; 1 billable unit = 1 mg
Q9998	Injection, ustekinumab-aekn (selarsdi), biosimilar, 1 mg; 1 billable unit = 1 mg
Q9999	Injection, ustekinumab-aauz (otulfi), biosimilar, 1mg; 1 billable unit = 1 mg

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HCPCS Codes (listed)HCPCS

J3357	Ustekinumab, subcutaneous, 1 mg; 1 billable unit = 1 mg
J3358	Ustekinumab, intravenous, 1 mg; 1 billable unit = 1 mg
J3590	Unclassified biologics (Discontinue use on 07/01/2026)
C9399	Unclassified drugs or biologicals (Discontinue use on 07/01/2026)
Q5137	ustekinumab-auub (wezlana), subcutaneous, 1 mg
Q5138	ustekinumab-auub (wezlana), intravenous, 1 mg
Q9996	ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg
Q9997	ustekinumab-ttwe (pyzchiva), intravenous, 1 mg
Q9998	ustekinumab-aekn (selarsdi), 1 mg
Q9999	ustekinumab-aauz (otulfi), 1 mg

Additional HCPCS/Q CodesHCPCS

Q5098	ustekinumab-srlf (imuldosa), 1 mg
Q5100	ustekinumab-kfce (yesintek), 1 mg
Q5099	ustekinumab-stba (steqeyma), 1 mg
Q5164	ustekinumab-hmny (starjemza), 1 mg

ICD-10 Codes (sample start)ICD-10

D71.1	Leukocyte adhesion deficiency
K50.00	Crohn's disease of small intestine without complications

ICD-10 Codes (Crohn's disease and Ulcerative colitis continued)ICD-10

K50.011	Crohn's disease of small intestine with rectal bleeding
K50.012	Crohn's disease of small intestine with intestinal obstruction
K50.013	Crohn's disease of small intestine with fistula
K50.014	Crohn's disease of small intestine with abscess
K50.018	Crohn's disease of small intestine with other complication
K50.019	Crohn's disease of small intestine with unspecified complications
K50.10	Crohn's disease of large intestine without complications
K50.111	Crohn's disease of large intestine with rectal bleeding
K50.112	Crohn's disease of large intestine with intestinal obstruction
K50.113	Crohn's disease of large intestine with fistula

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ICD-10 Codes (Ulcerative colitis continued)ICD-10

K51.20	Ulcerative (chronic) proctitis without complications
K51.211	Ulcerative (chronic) proctitis with rectal bleeding
K51.212	Ulcerative (chronic) proctitis with intestinal obstruction
K51.213	Ulcerative (chronic) proctitis with fistula
K51.214	Ulcerative (chronic) proctitis with abscess
K51.218	Ulcerative (chronic) proctitis with other complication
K51.219	Ulcerative (chronic) proctitis with unspecified complications
K51.30	Ulcerative (chronic) rectosigmoiditis without complications
K51.311	Ulcerative (chronic) rectosigmoiditis with rectal bleeding
K51.312	Ulcerative (chronic) rectosigmoiditis with intestinal obstruction

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Covered ICD-10 Diagnosis Codes (Subcutaneous group excerpts)ICD-10

K51.80	Other ulcerative colitis without complications
K51.811	Other ulcerative colitis with rectal bleeding
K51.812	Other ulcerative colitis with intestinal obstruction
K51.813	Other ulcerative colitis with fistula
K51.814	Other ulcerative colitis with abscess
K51.818	Other ulcerative colitis with other complication
K51.819	Other ulcerative colitis with unspecified complications
K51.90	Ulcerative colitis, unspecified, without complications
K51.911	Ulcerative colitis, unspecified with rectal bleeding
K51.912	Ulcerative colitis, unspecified with intestinal obstruction

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Covered ICD-10 Diagnosis Codes (Intravenous group excerpts)ICD-10

M08.911	Juvenile arthritis, unspecified, right shoulder
M08.912	Juvenile arthritis, unspecified, left shoulder
M08.919	Juvenile arthritis, unspecified, unspecified shoulder
M08.921	Juvenile arthritis, unspecified, right elbow
M08.922	Juvenile arthritis, unspecified, left elbow
M08.929	Juvenile arthritis, unspecified, unspecified elbow
M08.931	Juvenile arthritis, unspecified, right wrist
M08.932	Juvenile arthritis, unspecified, left wrist
M08.939	Juvenile arthritis, unspecified, unspecified wrist
M08.941	Juvenile arthritis, unspecified, right hand

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Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required for Ustekinumab and Biosimilars

Prior authorization is required for ustekinumab (intravenous and subcutaneous) and all listed biosimilars. Include applicable HCPCS/Q-codes with PA request and ensure documentation supports the requested product, route, and dosing.

Prior authorization validity: initial generally 6 months (180 days) unless specified otherwise; dose-escalation requests for Crohn's Disease and Ulcerative Colitis granted for 3 months (90 days) with conditions for continued renewal
Include documented ICD-10 diagnosis codes relevant to the request (see ICD-10 lists for subcutaneous and intravenous routes)

Documentation Required

Medicare Compliance and CMS References

When processing Medicare Part B claims, reviewers must refer to CMS guidance. National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and are binding where applicable.

Site of Care

Billing Rule

Infusion center — IV induction vs SC maintenance

IV induction is expected to be administered in an appropriate outpatient infusion setting; SC maintenance dosing is suitable for outpatient or home administration per product labeling.

Document lists IV induction and SC maintenance formulations; IV induction expected in outpatient infusion setting [[chunk 0]]
Policy dosing section specifies IV induction administered in infusion setting and SC maintenance for outpatient/home administration [[chunk 23]]

Billing Rule

Site‑of‑care for IV induction and SC maintenance

IV induction must be administered in an appropriate infusion setting; subsequent SC maintenance doses are intended for outpatient or home administration as clinically appropriate.

IV induction dosing and SC maintenance scheduling described in dosage/administration section; maintenance uses SC formulation for outpatient/home administration [[chunk 23]]

Biosimilar and Product Equivalence

Billing Rule

Stelara (ustekinumab) — billing and biosimilar equivalence

Stelara (ustekinumab) and listed biosimilars are presented with HCPCS/Q‑codes and NDCs and are treated as equivalent products for billing and dosing guidance.

HCPCS J3357 and J3358 plus multiple Q‑codes for biosimilars are listed in billing section [[chunk 26]]
Intravenous and single‑dose vial NDCs for Stelara and biosimilars are listed in the product availability section [[chunk 32]]

Background

Ustekinumab is a monoclonal antibody directed at the IL‑12/23 p40 pathway and is used in multiple inflammatory conditions across specialties. The policy outlines IV induction and SC maintenance regimens: for Crohn's disease IV induction is weight‑tiered (adult tiers include ≤55 kg: 260 mg; >55–85 kg: 390 mg; >85 kg: 520 mg) with typical adult subcutaneous maintenance of 90 mg given 8 weeks after the IV dose and every 8 weeks thereafter. For plaque psoriasis the approved SC loading and maintenance are weight‑based (e.g., ≤100 kg: 45 mg at weeks 0 and 4 then every 12 weeks; >100 kg: 90 mg at weeks 0 and 4 then every 12 weeks). The policy also lists pediatric weight‑based dosing tiers, describes monitoring and baseline screening obligations (latent TB, vaccination status), and includes dosing limits and conditions for dose escalation in inflammatory bowel disease.

Definitions

Phototherapy contraindications

Example: xeroderma pigmentosumAbsolute contraindication to phototherapy (PUVA/UVB)

Pregnancy/lactation (PUVA)Pregnancy or lactation is listed as a contraindication to PUVA

Photosensitizing medicationsUse of photosensitizing medications is a contraindication to PUVA

Severe organ diseaseSevere liver, renal, or cardiac disease is a contraindication to PUVA

Disease response

DefinitionDisease response = improvement in signs and symptoms compared to baseline (examples vary by indication)

Crohn's examples

Quantity and Dosing Limits

Ustekinumab dosing summary

Induction dose (IV)520 mg × 1 (intravenous induction)

Maintenance (CD/UC/ICI toxicities)90 mg subcutaneous at 8 weeks after induction, then 90 mg every 8 weeks

Maintenance (psoriasis)90 mg subcutaneous every 12 weeks for psoriasis maintenance

Step Therapy

Dose escalation limits — max 90 mg q4w

Maximum allowed dose escalation after loss of response for Crohn's disease and ulcerative colitis is up to 90 mg subcutaneously every 4 weeks.

Policy limit: escalation must not exceed 90 mg SC every 4 weeks; some members may benefit from smaller interval reductions (5–7 weeks) [[chunk 24]]
Trough guidance and escalation rationale referenced; trough <4.5 µg/mL may support interval shortening [[chunk 25]]

Revision History

2026-05-05policy_reviewLatest

Policy reviewed; last review documented as 2026-05-05 in the policy metadata.

2026-?billing_code_update

HCPCS/Q-code list includes codes with effective/discontinue dates called out (e.g., Q5164 effective 07/01/2026) noted in billing/code sections.

OpenPayer

Ustekinumab (IV/SC) coverage and prior authorization criteria

Coverage Criteria

Initial Therapy Criteria (Indication-specific)

Continuation and Renewal Criteria

Step Therapy Requirements

Coding

Provider Actions and Prior Authorization

Site of Care

Biosimilar and Product Equivalence

Background

Definitions

Quantity and Dosing Limits

Revision History