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Independence Blue CrossMedicare Advantage · Billing Codes · Pharmacy · Gastroenterology, Rheumatology, Oncology +2 moreHigh impact

MA08.042k, Ustekinumab for Intravenous Use

Act
by Jul 1, 2025
Effective date
Jul 1, 2025
Identified
Jun 19, 2026

Summary

Independence Blue Cross updated MA08.042m to add seven new ustekinumab biosimilar products with specific HCPCS codes and modifier requirements for intravenous use. The policy designates ustekinumab-kfce (Yesintek) as the preferred product and removes continuation therapy criteria since maintenance transitions to subcutaneous (non-covered). Coverage now includes pediatric use considerations for Crohn disease, ulcerative colitis, and checkpoint inhibitor toxicities.

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What to do

by Jul 1, 2025 · 5 steps
01Billing team must update system to recognize all nine ustekinumab HCPCS codes (J3358, Q5098, Q5099, Q5100, Q5138, Q5164, Q9997, Q9998, Q9999) as medically necessary for IV infusion.
02Configure billing software to require JA modifier (Administered Intravenously) when billing Q5098, Q5099, Q5100, Q9998, and Q9999; do NOT append JA to Q5138 or Q5164 per policy.
03Update prior authorization workflows to require documentation of contraindication, intolerance, or inadequate response to preferred product ustekinumab-kfce (Yesintek) before approving nonpreferred products.
04Ensure claims for subcutaneous maintenance therapy are routed to pharmacy benefit (Part D), not medical benefit (Part B).
05Providers must document patient age (≥18 years for UC, ≥2 years for CD) and absence of concurrent biologic DMARD therapy.
If missed: Failure to apply correct modifiers and route claims to correct benefit will result in denials.

Codes mentioned

J3358Q5098Q5099Q5100Q5138Q5164Q9997Q9998Q9999

Original notice

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

See all Independence Blue Cross changes →
MA08.042m, Ustekinumab for Intravenous InfusionMediumEffective Sep 21, 2026 · PharmacyMA08.042l, Ustekinumab for Intravenous UseHighEffective Jul 1, 2026 · Pharmacy08.00.82q, Ustekinumab for Intravenous InfusionHighEffective Jul 1, 2026 · 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 policiesGastroenterologyRheumatologyOncologyPediatricsPharmacyCode J3358Code Q5098Code Q5099Code Q5100Code Q5138Code Q5164Code Q9997Code Q9998Code Q9999

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