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Independence Blue CrossMedicare Advantage · Coverage · Pharmacy · Gastroenterology, Pediatrics, Pharmacy +1 moreMedium impact

MA08.042m, Ustekinumab for Intravenous Infusion

Act
by Sep 21, 2026
Effective date
Sep 21, 2026
Identified
Sep 22, 2026

Summary

Independence Blue Cross updated MA08.042m to expand ustekinumab IV coverage to pediatric patients aged 2+ with Crohn disease (previously 18+ only) and removed the biologic step therapy requirement for initial IV induction therapy. The preferred product remains ustekinumab-kfce (Yesintek), with nine nonpreferred biosimilar alternatives available upon documented contraindication, intolerance, or inadequate response.

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What to do

by Sep 21, 2026 · 4 steps
01Billing team must update claim submission rules to allow ustekinumab IV (HCPCS codes J3358, Q5098-Q5100, Q5138, Q5164, Q9997-Q9999) for pediatric patients age 2+ with Crohn disease without prior step therapy requirement for initial induction therapy.
02Remove any billing system logic that mandates biologic step therapy prior to ustekinumab IV authorization for new patients.
03Update prior authorization workflows to require documentation of contraindication, intolerance, or inadequate response only when requesting nonpreferred biosimilar products (Q5098, Q5099, Q5138, Q5164, Q9997-Q9999); preferred product Q5100 (Yesintek) should not require such documentation for initial therapy.
04Ensure providers and care coordinators are notified that pediatric Crohn disease patients can now access ustekinumab IV without step therapy delays.
If missed: Failure to implement these changes may result in claim denials or delayed authorizations for eligible pediatric patients.

Codes mentioned

J3358Q5098Q5099Q5100Q5138Q5164Q9997Q9998Q9999

Original notice

MA08.042m, Ustekinumab for Intravenous Infusion
medpolicy.ibx.com · Always check the source before changing claims.
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Related changes

See all Independence Blue Cross changes →
MA08.042l, Ustekinumab for Intravenous UseHighEffective Jul 1, 2026 · Pharmacy08.00.82q, Ustekinumab for Intravenous InfusionHighEffective Jul 1, 2026 · PharmacyMA08.042k, Ustekinumab for Intravenous UseHighEffective Jul 1, 2025 · Pharmacy08.00.82o, Ustekinumab for Intravenous Infusion and Subcutaneous InjectionHighEffective Jul 1, 2025 · PharmacyBrowse every Independence Blue Cross change in the policy list

Related policy hubs

Independence Blue Cross policiesGastroenterologyPediatricsPharmacyInternal MedicineCode J3358Code Q5098Code Q5099Code Q5100Code Q5138Code Q5164Code Q9997Code Q9998Code Q9999

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