Medicare AdvantagePrior AuthMedium impact
Preferred Ustekinumab Products (Revised)
Humana·Gastroenterology, Dermatology, Rheumatology·Medicare Advantage
Effective date
Jul 1, 2025
We identified it
Jun 24, 2026
Summary
This policy establishes prior authorization requirements for ustekinumab products (including Stelara, Otulfi, and Yesintek) for Medicare Advantage plans covering ulcerative colitis, Crohn's disease, psoriasis, and psoriatic arthritis. Specific step therapy requirements apply for generic IV ustekinumab under Medicare Part B, requiring trial of Remicade/Inflectra/Infliximab AND preferred ustekinumab products first.
Action Required
By July 1, 2025: Billing team must update prior authorization workflows for all ustekinumab products (Stelara, Otulfi, Yesintek) for Medicare Advantage patients. Providers must document age requirements (18+ for UC, 2+ for Crohn's, 6+ for psoriasis/PsA) and prior therapy requirements for Part B generic IV ustekinumab. Update EMR templates to capture required criteria and ensure prior auth is obtained before administering these medications to avoid claim denials.