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Non-preferred Ustekinumab Products (New)
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Oct 2, 2026
Summary
Effective January 1, 2027, Humana Medicare Advantage is implementing a new prior authorization policy for non-preferred ustekinumab products (Stelara, Imuldosa, Pyzchiva, Selarsdi, Starjemza, Steqeyma, and biosimilars). Providers must now document step-therapy requirements—patients must have tried or be unable to use specific preferred alternatives before non-preferred ustekinumab products can be approved. This is a pharmacy coverage policy requiring prior authorization for four indications: ulcerative colitis, Crohn's disease, chronic plaque psoriasis, and psoriatic arthritis.
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What to do
by Dec 31, 2026 · 9 steps
01Billing and clinical teams must implement the following for all Humana Medicare Advantage patients.
02Update prior authorization protocols in billing system to require step-therapy documentation before approving non-preferred ustekinumab products.
03For ulcerative colitis and Crohn's disease IV formulations: verify patient has tried or cannot use Remicade, Avsola, Infliximab AND a preferred ustekinumab product (Otulfi, Yesintek) or Tremfya.
04For subcutaneous formulations of these conditions: verify patient has tried or cannot use TWO of the following—preferred adalimumab (adalimumab-adbm, adalimumab-adaz), preferred ustekinumab (Otulfi, Yesintek), Skyrizi, Rinvoq, or Tremfya.
05For chronic plaque psoriasis SC only: verify TWO prior trials from—preferred adalimumab, Enbrel, Cosentyx, Skyrizi, preferred ustekinumab, or Tremfya.
06For psoriatic arthritis SC only: verify TWO prior trials from—preferred adalimumab, Enbrel, Skyrizi, Cosentyx, Rinvoq, preferred ustekinumab, Tremfya, or Otezla.
07Update encounter templates and PA request forms to capture step-therapy history.
08Train providers and billing staff on age requirements (18+ for UC, 2+ for Crohn's, 6+ for psoriasis and PsA).
09Note: Medicare Part B requests do not require step-therapy if continuation of prior therapy within 365 days.
If missed: Failure to obtain prior authorization or document step-therapy will result in claim denials for all non-preferred ustekinumab products.
Original notice
Non-preferred Ustekinumab Products (New)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Preferred Ustekinumab Products (Revised)HighEffective Jul 1, 2025 · Medicare AdvantagePreferred Ustekinumab Products (Revised)MediumEffective Jul 1, 2025 · Medicare AdvantageNon-preferred Ustekinumab Products (Revised)HighEffective Jan 1, 2026 · Medicare AdvantageBrowse every Humana change in the policy list