Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Preferred Agents:
Crohn's Disease (CD)
Anti-TNF Inhibitors
HUMIRA (adalimumab)
Ulcerative Colitis (UC)
Anti-TNF Inhibitors
HUMIRA (adalimumab)
Janus Kinase (JAK) Inhibitors
XELJANZ (tofacitinib)
XELJANZ XR (tofacitinib)
The use of ustekinumab (Stelara) IV may be considered medically necessary when the following criteria are met:
For Crohn's Disease (CD):
- The individual must have an FDA-approved indication for use (meets label recommendations for diagnosis and age); and
- The individual must have had a 3-month trial of a preferred agent from each class approved for patient’s diagnosis, as
evidenced by paid claims or pharmacy printouts.
For Ulcerative Colitis (UC):
- The individual must have an FDA-approved indication for use (meets label recommendations for diagnosis and age); and
- The individual must have had a 30-day trial of a preferred agent or a TNF inhibitor, as evidenced by paid claims or pharmacy printouts.
NOTE: If approved, ustekinumab (Stelara) IV will be allowed as a single intravenous infusion.
Ustekinumab (Stelara) IV for any other indication is considered experimental/investigational and therefore non-covered. Scientific evidence has not established the effectiveness for any other indication.
Procedure Codes
