Stelara® (ustekinumab)

Authorization forms

(forms cover both IV and subcutaneous formulations)

Traditional & Optimized (11/2018)

Medicare Part D (01/2019)

Stelara is not covered for Medicaid

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J3357 (sc), Q9989 (iv)

Benefit: Medical

Notes: Treatment of moderate to severe plaque psoriasis