CommercialPrior AuthHigh impact
Ustekinumab (CPB 0912, reviewed 2026-07-01)
Aetna·Dermatology, Rheumatology, Gastroenterology +2 more·Medical Policy
Effective date
Jul 1, 2026
We identified it
Aug 18, 2026
Summary
Aetna (CPB 0912) significantly restricts coverage of nine ustekinumab biosimilars (Imuldosa, Otulfi, Pyzchiva non-Sandoz, Selarsdi, Starjemza, Steqeyma, unbranded Stelara, Wezlana, Yesintek), designating them as medically necessary only when patients fail contraindication/intolerance/inefficacy trials on lower-cost alternatives. This policy requires step-therapy with 5-6 competing biologics before approving higher-cost ustekinumab products. Billing teams must implement precertification workflows and step-therapy documentation requirements immediately.
Action Required
By July 1, 2026: Billing and prior authorization teams must implement the following:
1. PRECERTIFICATION REQUIREMENT: Update billing system to require mandatory precertification for ALL ustekinumab products (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Starjemza, Steqeyma, Wezlana, Yesintek) before claim submission. Contact Aetna at (866) 752-7021 or fax (888) 267-3277 for precertification.
2. STEP-THERAPY DOCUMENTATION: For requests involving the nine biosimilars (all except Sandoz-labeled Pyzchiva and unbranded Stelara), require providers to submit evidence that the patient has failed or cannot tolerate ALL of the following alternatives per indication:
- Crohn's Disease/UC: Entyvio, Skyrizi, Pyzchiva/Stelara, Tremfya, and Avsola/Inflectra/Renflexis (minimum 1-month trial each)
- Psoriatic Arthritis: Simponi Aria, Skyrizi, Pyzchiva/Stelara, Tremfya, and Avsola/Inflectra/Renflexis (minimum 1-month trial each)
- Plaque Psoriasis: Ilumya, Skyrizi, Pyzchiva/Stelara, Tremfya, and Avsola/Inflectra/Renflexis (minimum 1-month trial each)
3. PROVIDER NOTIFICATION: Send written notice to all dermatologists, rheumatologists, gastroenterologists, hematologists, and oncologists specifying:
- Only dermatologists may prescribe for plaque psoriasis
- Only rheumatologists/dermatologists for psoriatic arthritis
- Only gastroenterologists for CD/UC
- Only gastroenterologists/hematologists/oncologists for checkpoint inhibitor toxicity
4. CLAIM DENIAL PROTOCOL: Establish system rule to deny or hold claims for the nine biosimilars if step-therapy documentation is incomplete. Claims submitted without evidence of failed trials on required alternatives will be denied.
5. UPDATE ENCOUNTER FORMS: Add checkbox on specialty encounter forms reminding providers to document step-therapy failures and contraindications/intolerances in clinical notes before requesting these higher-cost products.
FAILURE TO IMPLEMENT: Claims for restricted ustekinumab biosimilars will be denied without precertification and step-therapy documentation, resulting in revenue loss and patient appeals.