When does this change take effect?

This change is effective Dec 1, 2026.

What do I need to do?

Before December 1, 2026: Submit the documentation needed to start prior authorization review for each ustekinumab product. For initial plaque psoriasis requests, send chart notes or medical record documentation of the affected areas and body surface area (BSA) affected, and chart notes, medical records or claims history showing previous medications tried and their response, or the clinical reason to avoid therapy if therapy is not advisable. For PsO continuation requests, send chart notes or medical record documentation of decreased BSA affected and/or improvement in signs and symptoms. For PsA, CD and UC continuation requests, send chart notes or medical record documentation of a positive clinical response to therapy, or remission for CD and UC. Document that the member has been evaluated for tuberculosis (TB) infection before starting treatment. The medication must be prescribed by or in consultation with a dermatologist for PsO, a rheumatologist or dermatologist for PsA, a gastroenterologist for CD and UC, and a gastroenterologist, hematologist or oncologist for immune checkpoint inhibitor-related toxicity. Do not use it concomitantly with any other biologic or targeted synthetic drug for the same indication. Some agents on this policy may require step therapy, as described in the Step Therapy Requirements for Provider Administered Specialty Medications document. Approvals may be subject to the dosing and quantity limits listed in the policy for each product, route and indication.

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BCBS TennesseeAll Plans · Prior Auth · Medical Policy · TN · Dermatology, Rheumatology, Gastroenterology +2 moreMedium impact

Ustekinumab Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab-srlf (Imuldosa™); Ustekinumab-aauz (Otulfi™); Ustenkinumab-ttwe (Pyzchiva™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustekinumab-auub; ustenkinumabttwe, Ustekinumab-hmny (Starjemza)

Q: Who is affected by this change?

This affects BCBS Tennessee Dermatology, Rheumatology, Gastroenterology, Hematology, Oncology providers in TN on All Plans plans.

Effective date

Dec 1, 2026

Identified

Sep 10, 2026

Summary

Effective December 1, 2026, BlueCross BlueShield of Tennessee's ustekinumab medical policy sets coverage criteria for the ustekinumab products it lists, including Stelara, for plaque psoriasis (PsO), psoriatic arthritis (PsA), Crohn's disease (CD), ulcerative colitis (UC) and immune checkpoint inhibitor-related toxicity. Authorization of 12 months may be granted for PsO, PsA, CD and UC when the criteria are met, and 6 months may be granted for immune checkpoint inhibitor-related diarrhea or colitis when the member has an inadequate response, intolerance or contraindication to infliximab or vedolizumab. All other indications are considered experimental/investigational and not medically necessary.

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What to do

Action · 9 steps

01Before December 1, 2026: Submit the documentation needed to start prior authorization review for each ustekinumab product.

02For initial plaque psoriasis requests, send chart notes or medical record documentation of the affected areas and body surface area (BSA) affected, and chart notes, medical records or claims history showing previous medications tried and their response, or the clinical reason to avoid therapy if therapy is not advisable.

03For PsO continuation requests, send chart notes or medical record documentation of decreased BSA affected and/or improvement in signs and symptoms.

04For PsA, CD and UC continuation requests, send chart notes or medical record documentation of a positive clinical response to therapy, or remission for CD and UC.

05Document that the member has been evaluated for tuberculosis (TB) infection before starting treatment.

06The medication must be prescribed by or in consultation with a dermatologist for PsO, a rheumatologist or dermatologist for PsA, a gastroenterologist for CD and UC, and a gastroenterologist, hematologist or oncologist for immune checkpoint inhibitor-related toxicity.

07Do not use it concomitantly with any other biologic or targeted synthetic drug for the same indication.

08Some agents on this policy may require step therapy, as described in the Step Therapy Requirements for Provider Administered Specialty Medications document.

09Approvals may be subject to the dosing and quantity limits listed in the policy for each product, route and indication.

Original notice

Ustekinumab Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab-srlf (Imuldosa™); Ustekinumab-aauz (Otulfi™); Ustenkinumab-ttwe (Pyzchiva™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustekinumab-auub; ustenkinumabttwe, Ustekinumab-hmny (Starjemza)

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Related changes

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Related policy hubs

BCBS Tennessee policies TN policy changes Dermatology Rheumatology Gastroenterology Hematology Oncology