HCPCS J3357 is officially defined as "Ustekinumab, for subcutaneous injection, 1 mg." HCPCS J3357 is referenced in 13 tracked payer policy changes from Sentara Health Plans, Blue Cross & Blue Shield of Mississippi, and 8 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J3357 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Remicade, infliximab, Neulasta, Neulasta Onpro, Kanjinti, and Selarsdi will no longer be covered effective 01/01/2027, and services related to delivery or administration of a not covered or non-formulary medication are considered not medically necessary. Prolia, Soliris, and Xgeva were set to no longer be covered effective 08/15/2026, and a policy update dated 11/01/2026 added Avsola, Fulphila, Fylnetra, Granix, Ogivri, Ontruzant, Renflexis, Riabni, Starjemza, and Vegzelma as covered products.
Arkansas Blue Cross updated authorization renewal criteria for three medications: Tagraxofusp-erzs (Elzonris), Ustekinumab (Stelara) including preferred/non-preferred product lists and expanded age criteria for Crohn's disease from 18+ to 2+ years, and Denosumab (Xgeva/Prolia) with updated off-label indications. All changes include new preferred product formulations with specific HCPCS codes.
Effective August 1, 2026, Texas Medicaid will require specific diagnosis codes to be submitted with Stelara claims (HCPCS codes J3357 and J3358). Claims must include at least one diagnosis code from the approved lists for Psoriasis Arthritis, Plaque Psoriasis, Crohn's Disease, or Ulcerative Colitis to receive reimbursement. Billing teams must update claim submission protocols and provider documentation requirements immediately.
Independence Blue Cross has updated policy 08.00.82p to 08.00.82r, effective 01/01/2026. The critical change: subcutaneous ustekinumab formulations and their indications for plaque psoriasis and psoriatic arthritis are NO LONGER COVERED under the Medical Benefit. Only intravenous formulations remain covered for Crohn disease, ulcerative colitis, and immune-checkpoint inhibitor–related toxicity. All subcutaneous HCPCS codes (J3357, Q5137, Q9996) have been removed from the policy, and the JA modifier (intravenous administration) is now required for all IV claims.
Aetna considers measurement of antidrug antibodies and or serum drug levels for adalimumab, certolizumab, golimumab, or infliximab medically necessary for members with Crohn's disease or ulcerative colitis when there is documentation of a loss of response to one of these medications, or for proactive monitoring in members 21 years of age or younger with a confirmed diagnosis of IBD. Aetna considers serum antibody measurements for anti-TNF therapies experimental, investigational, or unproven for all other indications, such as psoriasis, psoriatic arthritis, rheumatoid arthritis, spondyloarthritis, and uveitis. Anti-histone antibody measurement for monitoring infliximab and DNA or mRNA biomarker measurement for predicting therapeutic response in IBD are also considered experimental, investigational, or unproven.
Aetna considers measurement of antidrug antibodies and/or serum drug levels to adalimumab, certolizumab, golimumab or infliximab medically necessary for members with inflammatory bowel disease (Crohn's disease or ulcerative colitis) when there is documentation of a loss of response to one of these medications, or for proactive monitoring in members 21 years of age or younger with a confirmed IBD diagnosis. Measurement of anti-histone antibodies for monitoring infliximab therapy and measurement of DNA or mRNA biomarkers for predicting therapeutic response in IBD are considered experimental, investigational or unproven. Serum level and antibody testing of anti-TNF blocking agents for all other indications, such as psoriasis, psoriatic arthritis, rheumatoid arthritis, spondyloarthritis and uveitis, is also considered experimental, investigational or unproven.
Independence Blue Cross updated policy 08.00.78aw to 08.00.78ay, effective 01/01/2026, adding nine FDA-approved self-administered drugs/biologics to Attachment A (including Forzinity, Lasix Onyu, Redemplo, Sandostatin, multiple Ustekinumab brands, and Vyvgart Hytrulo) and four pending FDA-approval drugs. Self-administered drugs remain non-covered under the medical benefit but may be available through pharmacy benefits; billing teams must verify individual member coverage and direct patients to specialty pharmacy.
Procise ADL, Procise IFX, PredictrPK IFX, ADALX, Anser ADA, Anser IFX, Anser UST and Anser VDZ are considered investigational when used to measure serum drug or antibody levels for biologic therapies. Tests that predict response or non-response to biologic therapies, such as PrismRA alone or as a combination test, are also considered investigational. Code 0456U was deleted in the 11/20/25 annual review.
CareSource Georgia Medicaid has revised the pharmacy policy for TREMFYA (Guselkumab), effective June 18, 2025. The specific details of the revision are not provided in this notification document; billing teams must access the full policy on CareSource.com to determine what coverage, prior authorization, or reimbursement changes apply.
Effective December 1, 2022, breast pumps can be prescribed by certified nurse midwives as well as physicians, physician assistants and nurse practitioners, and HCPCS codes L8614 (cochlear device) and 31599 (gender-affirming surgeries) require prior authorization requests. Effective for dates of service on or after January 1, 2023, fingertip pulse oximeters billed under E0445 use modifier U1 and tabletop pulse oximeters use modifier U2, with U2 rates the same as the current E0445 rate. Effective January 1, 2023, a select group of additional physician-administered drugs, including Simponi, Stelara, Orencia, Tezspire, Oxlumo and three Duchenne muscular dystrophy drugs, are subject to prior authorization.
Effective January 1, 2023, claims billed with HCPCS 2023 procedure codes may begin suspending for EOB 0000, and claims will be released once the Colorado interChange update is complete. Effective January 1, 2023, a select group of additional physician-administered drugs require prior authorization, and prior authorization for CPT 92526 is no longer required when billed with CPT 74230 and 92611, while the multi-user breast pump rate for E0604 with modifier RR is $219.67. Depression screen claims using G8431 or G8510 must include U modifiers beginning July 1, 2023, after that requirement was postponed again, and claims without modifiers will be denied.
Carelon Medical Benefits Management clinical appropriateness guidelines for genetic testing, radiation therapy, advanced imaging and oncologic imaging were updated for dates of service on and after March 17, April 14 and June 30, 2024. Carelon also began applying its clinical appropriateness guidelines and cancer treatment pathways effective March 7, 2024. Premera HMO medical policies and drug criteria were revised under effective dates of March 1, April 4 and June 7, 2024, and Federal employee plans received new cervical spine, lumbar spine and site of service surgery policies effective March 7, 2024.
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