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08.00.82o, Ustekinumab for Intravenous Infusion and Subcutaneous Injection
Act
by Jun 30, 2025
Effective date
Jul 1, 2025
Identified
Jun 19, 2026
Summary
Independence Blue Cross updated policy 08.00.82o to version 08.00.82r, effective July 1, 2025, adding nine new ustekinumab biosimilar HCPCS codes and designating ustekinumab-kfce (Yesintek) as the preferred product. The policy clarifies routes of administration for Crohn disease, ulcerative colitis, and immune-checkpoint inhibitor-related toxicities, and adds experimental/investigational designation for pediatric use of these conditions.
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What to do
by Jun 30, 2025 · 6 steps
01Billing team must update billing system to recognize all nine new ustekinumab biosimilar HCPCS codes (Q5098, Q5099, Q5100, Q5137, Q5138, Q9996, Q9997, Q9998, Q9999) as medically necessary for coverage under IBX Commercial plans.
02Establish preferred product edits in billing software to flag ustekinumab-kfce (Yesintek) as preferred and all other formulations as non-preferred, requiring documentation of contraindication, intolerance, or inadequate response before approval.
03Update prior authorization workflows to require documentation of clinical response period per clinical trial for non-preferred products.
04Configure system to route Starjemza (ustekinumab-hmny) claims using C9399 or J3590 codes through appropriate verification process.
05Notify providers that concurrent biologic DMARD therapy (anti-TNF agents) is not permitted with ustekinumab and educate on age restrictions: minimum 18 years for ulcerative colitis, minimum 2 years for Crohn disease.
06Document that pediatric use for Crohn disease, ulcerative colitis, or immune-checkpoint inhibitor-related toxicities is experimental/investigational.
If missed: Failure to implement preferred product edits and non-preferred product documentation requirements will result in claim denials or delays.
Codes mentioned
J3358Q5098Q5099Q5100Q5137Q5138Q9996Q9997Q9998Q9999Q5164C9399J3590
Original notice
08.00.82o, Ustekinumab for Intravenous Infusion and Subcutaneous Injection
medpolicy.ibx.com · Always check the source before changing claims.
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 · Pharmacy08.00.82p, Ustekinumab for Intravenous InfusionHighEffective Jan 1, 2026 · PharmacyMA08.042m, Ustekinumab for Intravenous InfusionMediumEffective Sep 21, 2026 · PharmacyBrowse every Independence Blue Cross change in the policy list