Medicare AdvantageCoverageMedium impact
MA08.042k, Ustekinumab for Intravenous Use
Independence Blue Cross·Rheumatology, Gastroenterology, Dermatology +1 more·Pharmacy
Effective date
Jul 1, 2025
We identified it
Jun 19, 2026
Summary
Policy MA08.042k establishes coverage and medical necessity criteria for ustekinumab (Stelara) administered intravenously. This recent policy update (effective 07/01/2025) affects how IV ustekinumab claims are billed, coded, and approved under Medicare Advantage plans. The billing team must implement new medical necessity requirements and ensure claims comply with updated coding and reimbursement guidelines.
Action Required
By 07/01/2025: (1) Billing team must obtain and review the complete policy text at the provided URL to identify specific HCPCS codes for IV ustekinumab administration and any prior authorization requirements. (2) Update billing system to enforce medical necessity criteria for ustekinumab IV claims—ensure providers document indication and clinical justification before submission. (3) Providers must be notified of any new prior authorization workflows or documentation requirements. (4) Update claim scrubbing rules to flag ustekinumab IV claims for medical necessity validation. (5) Train billing staff on correct coding per updated guidelines. Claims submitted without proper medical necessity documentation or using incorrect codes will be denied or delayed. Contact IBX directly if specific codes and approval workflows are not clearly defined in the full policy text.