Coverage Policy Manual
Policy #: 2021028
Category: Pharmacy
Initiated: September 2021
Last Review: June 2024
  Ustekinumab (e.g., Stelara) and Biosimilars
Description:
Ustekinumab, a humanized monoclonal antibody, is an interleukin-12 (IL-12) and interkeukin-23 ((IL-23) antagonist. Ustekinumab binds to the p40 protein subunit, used by both IL-12 and IL-23 cytokines, and disrupts their interaction with receptors. This interaction inhibits the release of proinflammatory cytokines that have been implicated as important contributors to the chronic inflammation in both Crohn’s disease and ulcerative colitis.  
 
Regulatory Status
 
Ustekinumab (e.g., StelaraTM) is approved by the U.S. Food and Drug Administration (FDA) for treatment of the following:
    • Adult individuals with moderate to severe plaque psoriasis (Ps) who are candidates for phototherapy or systemic therapy
    • Adult individuals with active psoriatic arthritis (PsA), alone or in combination with methotrexate
    • Adult individuals with moderately to severely active Crohn’s disease (CD)    
    • Adult individuals with moderately to severely active ulcerative colitis (UC)
    • Pediatric individuals 6 years and older with moderate to severe plaque psoriasis, who are candidates for phototherapy or systemic therapy.
 
Ustekinumab solution for intravenous infusion is indication for the single dose induction phase in CD and UC.
 
Ustekinumab subcutaneous injection is indicated for the Ps, PsA, and the maintenance phase of CD and UC.
 
On July 29, 2022, the U.S. Food and Drug Administration approved ustekinumab to include the treatment of pediatric individuals 6 years and older with active psoriatic arthritis.
 
Coding
 
See CPT/HCPCS Code section below.
Policy/
Coverage:
Effective September 1, 2021 Prior Approval is required for Ustekinumab.
 
The initial use of this drug requires documentation of direct physician involvement and signature in the ordering and evaluation as documented in the medical records submitted for prior approval. Concurrent review will require continued evidence of appropriate physician involvement.  
 
The Step Therapy Medication Act is applicable to fully-insured (Arkansas Blue Cross, Health Advantage, and Exchange) and specified governmental (ASE/PSE and ASP) health plans. The law is not applicable to FEP or self-insured ERISA groups (including but not limited to Walmart or other Blue Advantage groups). Initial approval for exigent request is 28 days. Otherwise, initial approval for standard review is up to 1 year.
 
Effective June 26, 2024
 
Meets Primary Coverage Criteria or Is Covered for Contracts Without Primary Coverage Criteria
 
Ustekinumab meets primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when ALL the following criteria are met based on diagnosis:
 
CROHN’S DISEASE
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
 
1. Individual is greater than or equal to 18 years of age; AND
2. Individual has a diagnosis of moderate to severe Crohn’s disease supported by the submitted medical records; AND
3. Individual has an active disease with documented inadequate response (trial of ≥3 months) to at least one conventional therapy option (e.g., betamethasone, methylprednisolone, prednisolone, prednisone, budesonide, hydrocortisone, azathioprine, mercaptopurine, sulfasalazine, mesalamine, methotrexate) (Lichtenstein, 2018); OR
4. Individual has an active disease with intolerance or contraindication to at least one conventional therapy option (e.g., betamethasone, methylprednisolone, prednisolone, prednisone, budesonide, hydrocortisone, azathioprine, mercaptopurine, sulfasalazine, mesalamine, methotrexate) (Van Rheenen, 2021); OR
5. Individual has previously received a biologic (e.g., adalimumab, infliximab, certolizumab pegol, risankizumab, ustekinumab, natalizumab, vedolizumab) or Janus Kinase Inhibitor (e.g., upadacitinib) indicated for moderate to severe Crohn’s disease; OR
6. Individual has fistulizing disease (Feuerstein, 2021); AND
7. Individual is not using the medication in combination with any other biologic, including but not limited to: TNF inhibitor, IL-36 inhibitor, integrin inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
8. Individual does not have latent tuberculosis or serious active infection; AND
9. Must be dosed in accordance with the FDA label.
 
CONTINUED APPROVAL for up to 1 year:
 
1. Individual has met initial criteria for a diagnosis of Crohn’s disease; AND
2. Individual has experienced a documented positive clinical response; AND
3. Individual is not using the medication in combination with any other biologic, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
4. Must be dosed in accordance with the FDA label.
 
ULCERATIVE COLITIS
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
 
1. Individual is greater than or equal to 18 years of age; AND
2. Individual has a diagnosis of moderate to severe ulcerative colitis supported by the submitted medical records; AND
3. Individual has an active disease with documented inadequate response (trial of ≥3 months) to at least one conventional therapy option (e.g., mesalamine, sulfasalazine, olsalazine, balsalazide, betamethasone, prednisone, prednisolone, methylprednisolone, triamcinolone, hydrocortisone, budesonide, corticotropin) (ECCO 2022); OR
4. Individual has an active disease with intolerance or contraindication to at least one conventional therapy option (e.g., mesalamine, sulfasalazine, olsalazine, balsalazide, betamethasone, prednisone, prednisolone, methylprednisolone, triamcinolone, hydrocortisone, budesonide, corticotropin) (ECCO 2022); OR
5. Individual has previously received a biologic (e.g., adalimumab, infliximab, golimumab, ustekinumab, vedolizumab, mirikizumab) or targeted synthetic drug (e.g., tofacitinib, upadacitinib, ozanimod, etrasimod) indicated for ulcerative colitis; AND
6. Individual is not using the medication in combination with other biologic intended for treatment of ulcerative colitis, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
7. Individual does not have latent tuberculosis or serious active infection; AND
8. Must be dosed in accordance with the FDA label.  
 
CONTINUED APPROVAL for up to 1 year:
 
1. Individual has met initial criteria for a diagnosis of ulcerative colitis; AND
2. Individual has experienced a documented positive clinical response; AND
3. Individual is not using the medication in combination with other biologic intended for treatment of ulcerative colitis, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
4. Must be dosed in accordance with the FDA label.
 
PSORIATIC ARTHRITIS
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
 
1. Individual is greater than or equal to 6 years of age; AND
2. Individual has a diagnosis of moderate to severe psoriatic arthritis supported by the submitted medical records; AND
3. Individual has an active disease with documented inadequate response (trial of ≥3 months) to at least one conventional synthetic DMARDs (e.g., methotrexate, sulfasalazine, leflunomide) or phosphodiesterase 4 inhibitor (e.g., apremilast) (Ogdie, 2020); OR
4. Individual has an active disease with documented intolerance or contraindication to at least one conventional synthetic DMARDs (e.g., methotrexate, sulfasalazine, leflunomide) or phosphodiesterase 4 inhibitor (e.g., apremilast) (Ogdie, 2020); OR
5. Individual has previously received a biologic (e.g., etanercept, infliximab, ustekinumab, adalimumab, golimumab, certolizumab pegol, abatacept, secukinumab, ixekizumab, guselkumab) or oral Janus kinase inhibitor (e.g., tofacitinib, upadacitinib) indicated for psoriatic arthritis (Ogdie, 2020); OR
6. Individual has axial disease that is not responsive to treatment with NSAIDs, physiotherapy or sacroiliac joint glucocorticoid injections (GRAPPA, 2022); AND
7. Individual is not using the medication in combination with other biologic intended for treatment of psoriatic arthritis, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
8. Individual does not have latent tuberculosis or serious active infection; AND
9. Must be dosed in accordance with the FDA label.
 
CONTINUED APPROVAL for up to 1 year:
 
1. Individual has met criteria for initial approval; AND
2. Individual has experienced a documented positive clinical response; AND
3. Individual is not using the medication in combination with other biologic intended for treatment of psoriatic arthritis, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
4. Must be dosed in accordance with the FDA label.
 
PLAQUE PSORIASIS
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
 
1. Individual is greater than or equal to 6 years of age; AND
2. Individual has a diagnosis of moderate to severe plaque psoriasis established by or in consultation with a dermatologist as indicated by one of the following (AAD, 2019):   
a. Plaque psoriasis involving ≥ 3% body surface area (BSA) (Reich, 2017); OR   
b. Plaque psoriasis including areas that significantly impact daily function (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) (AAD, 2019); AND
3. Individual has an active disease with documented inadequate response (trial of ≥ 3 months) to phototherapy (e.g., UVB, PUVA) or at least one oral systemic treatment (e.g., methotrexate, cyclosporine, apremilast, acitretin); OR
4. Individual has an active disease with documented intolerance/contraindication to phototherapy (e.g., UVB, PUVA) or at least one oral systemic treatment (e.g., methotrexate, cyclosporine, apremilast, acitretin); OR
5. Individual has previously received a biologic (e.g., etanercept, infliximab, ustekinumab, adalimumab, certolizumab pegol, brodalumab, tildrakizumab, risankizumab, secukinumab, ixekizumab, guselkumab, alefacept, bimekizumab) or oral tyrosine kinase inhibitor (e.g., deucravacitinib) indicated for moderately to severely active plaque psoriasis (Menter, 2020); AND
6. Individual will not be using the medication in combination with any other biologic, including but not limited to: TNF inhibitor, PDE4 inhibitor, any IL inhibitor, or tyrosine kinase inhibitor; AND
7. Individual does not have latent tuberculosis or serious active infection; AND
8. Must be dosed in accordance with the FDA label.
 
CONTINUED APPROVAL for up to 1 year: 
 
1. Individual has met criteria for initial approval; AND
2. Individual has experienced a documented positive clinical response; AND
3. Individual is not using the medication in combination with any other biologic, including but not limited to: TNF inhibitor, PDE4 inhibitor, any IL inhibitor, or tyrosine kinase inhibitor; AND
4. Must be dosed in accordance with the FDA label.
 
POLICY GUIDELINES
 
Ulcerative Colitis
 
Moderate to severe ulcerative colitis is characterized by the following:
 
    1. Frequent stools (6 or more per day)
    2. Frequent blood in stools
    3. Frequent urgency
    4. Hemoglobin <75% of normal
    5. Erythropoietin Sedimentation Rate  >30
    6. Elevated C-reactive protein
    7. Fecal calprotectin >150-200
    8. Ulcerative Colitis Endoscopic Index of Severity of 5-8
 
Ulcerative Colitis activity index according to American College of Gastroenterology:
 
    1. Remission: daily formed stools, no blood in stool, no urgency, normal hemoglobin, < 30 erythrocyte sedimentation rate (ESR), normal C-reactive protein (CRP), < 150-000 fecal calprotectin (FC), 0-1 Ulcerative Colitis Endoscopic Index of Severity (UCEIS).
    2. Mild: < 4 stools per day, intermittent bloody stools, occasional urgency, normal hemoglobin, < 30 ESR, elevated     CRP, > 150-200 RC, 2-4 UCEIS.
    3. Moderate - Severe: > 6  stools per day, frequent blood in stools, urgency often, < 75% of normal hemoglobin, > 30 ESR, elevated CRP, > 150-200 FC, 5-8 UCEIS.
 
Psoriatic Arthritis
 
Diagnosis of psoriatic arthritis is based on the Classification Criteria for Psoriatic Arthritis (CASPAR), which require presence of inflammatory articular disease (joint, spine or entheseal) AND at least two of the following:
 
    1. Current psoriasis
    2. Personal history of psoriasis
    3. Family history of psoriasis in a first-or second- degree relative
    4. Presence of psoriatic nail dystrophy (onycholysis, pitting and hyperkeratosis)
    5. Rheumatoid factor negative
    6. Current dactylitis or history of dactylitis recorded by a rheumatologist.
    7. Juxtaarticular new bone formation on hand or foot x-ray.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
 
Plaque psoriasis disease activity according to Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics:
 
    1. Mild: < 3% BSA
    2. Moderate: 3% - 10% BSA
    3. Severe: >10% BSA, serious emotional consequences, or when it occurs in select locations, including but not restricted to, the hands, feet, scalp, face, or genital area, or when it causes intractable pruritus.
 
Dosage and Administration
Dosing per FDA Guidelines
 
The recommended dose of Ustekinumab is based on indication:
 
Plaque psoriasis adult subcutaneous injection:
 
    1. The recommended dosage for an individual weighing less than or equal to 100 kg is 45 mg administered subcutaneously initially and 4 weeks later, followed by 45 mg administered subcutaneously every 12 weeks.
    2. The recommended dosage for an individual weighing greater than 100 kg is 90 mg administered subcutaneously initially and 4 weeks later, followed by 90 mg administered subcutaneously every 12 weeks.
 
Plaque psoriasis pediatric subcutaneous injection:
 
    1. The recommended dosage for an individual weighing less than 60 kg is 0.75 mg/kg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.
    2. The recommended dosage for an individual weighing 60 kg to 100 kg is 45 mg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.
    3. The recommended dosage for an individual weighing greater than 100 kg is 90 mg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.  
 
Psoriatic Arthritis subcutaneous injection:  
 
    1. The recommended dosage is 45 mg administered subcutaneously initially and 4 weeks later, followed by 45 mg administered subcutaneously every 12 weeks.
    2. For individuals with co-existent moderate-to-severe- plaque psoriasis weighing greater than 100 kg, the recommended dosage is 90 mg administered subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.
 
Psoriatic Arthritis – Pediatric (6 to 17 years old) subcutaneous injection:
 
    1. The recommended dosage for a pediatric individual weighing less than 60 kg is 0.75 mg/kg subcutaneously.
    2. The recommended dosage for a pediatric individual weighing 60 kg or more is 45 mg subcutaneously.
    3. The recommended dosage for a pediatric individual weighing greater than 100 kg with co-existent moderate-to-severe plaque psoriasis is 90 mg subcutaneously.
 
Crohn’s Disease and Ulcerative Colitis initial adult intravenous infusion:
 
    1. The recommended dosage for an individual weighing less than 55 kg is 260 mg in a single intravenous infusion.
    2. The recommended dosage for an individual weighing 55 kg to 85 kg is 390 mg in a single intravenous infusion.
    3. The recommended dosage for an individual weighing greater than 85 kg is 520 mg in a single intravenous infusion.
 
Crohn’s Disease and Ulcerative Colitis maintenance subcutaneous injection:
 
    1. The recommended dosage is 90 mg administered subcutaneously 8 weeks after the initial intravenous dose, then every 8 weeks thereafter.   
 
Ustekinumab is available as:
    • Subcutaneous Injection:
        • Injection: 45 mg/0.5 mL or 90 mg/mL solution in a single-dose prefilled syringe.
        • Injection: 45 mg/0.5 mL solution in a single-dose vial.
    • Intravenous Infusion:
        • Injection: 130 mg/26 mL (5 mg/mL) solution in a single-dose vial.
 
Ustekinumab intravenous infusion (J3358) will only be available for a one-time initial infusion.
 
Ustekinumab intravenous infusion should be administered by a healthcare professional. In pediatric individuals, Ustekinumab subcutaneous injection should be administered by a healthcare professional.
 
Please refer to a separate policy on Site of Care or Site of Service Review policy #2018030 for pharmacologic/biologic medications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Ustekinumab, for any indication or circumstance not described above, does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, Ustekinumab, for any indication or circumstance not described above, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective January 2024 to June 25, 2024
 
Meets Primary Coverage Criteria or Is Covered for Contracts Without Primary Coverage Criteria
 
The use of Ustekinumab meets primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when ALL of the following criteria are met based on diagnosis:
 
CROHN’S DISEASE
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
1. Individual is greater than or equal to 18 years of age; AND
2. Individual has a diagnosis of moderate to severe Crohn’s disease supported by the submitted medical records; AND
3. Individual has an active disease with documented inadequate response (trial of ≥3 months) to at least one conventional therapy option (e.g., betamethasone, methylprednisolone, prednisolone, prednisone, budesonide, hydrocortisone, azathioprine, mercaptopurine, sulfasalazine, mesalamine, methotrexate) (Lichtenstein, 2018); OR
4. Individual has an active disease with intolerance or contraindication to at least one conventional therapy option (e.g., betamethasone, methylprednisolone, prednisolone, prednisone, budesonide, hydrocortisone, azathioprine, mercaptopurine, sulfasalazine, mesalamine, methotrexate) (Van Rheenen, 2021); OR
5. Individual has previously received a biologic (e.g., adalimumab, infliximab, certolizumab pegol, risankizumab, ustekinumab, natalizumab, vedolizumab) or Janus Kinase Inhibitor (e.g., upadacitinib) indicated for moderate to severe Crohn’s disease; OR
6. Individual has fistulizing disease (Feuerstein, 2021); AND
7. Individual is not using the medication in combination with any other biologic, including but not limited to: TNF inhibitor, IL-36 inhibitor, integrin inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
8. Individual does not have latent tuberculosis or serious active infection; AND
9. Must be dosed in accordance with the FDA label.
 
CONTINUED APPROVAL for up to 1 year:
1. Individual has met initial criteria for a diagnosis of Crohn’s disease; AND
2. Individual has experienced a documented positive clinical response; AND
3. Individual is not using the medication in combination with any other biologic, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
4. Must be dosed in accordance with the FDA label.
 
ULCERATIVE COLITIS
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
1. Individual is greater than or equal to 18 years of age; AND
2. Individual has a diagnosis of moderate to severe ulcerative colitis supported by the submitted medical records; AND
3. Individual has an active disease with documented inadequate response (trial of ≥3 months) to at least one conventional therapy option (e.g., mesalamine, sulfasalazine, olsalazine, balsalazide, betamethasone, prednisone, prednisolone, methylprednisolone, triamcinolone, hydrocortisone, budesonide, corticotropin) (ECCO 2022); OR
4. Individual has an active disease with intolerance or contraindication to at least one conventional therapy option (e.g., mesalamine, sulfasalazine, olsalazine, balsalazide, betamethasone, prednisone, prednisolone, methylprednisolone, triamcinolone, hydrocortisone, budesonide, corticotropin) (ECCO 2022); OR
5. Individual has previously received a biologic (e.g., adalimumab, infliximab, golimumab, ustekinumab, vedolizumab, mirikizumab) or targeted synthetic drug (e.g., tofacitinib, upadacitinib, ozanimod, etrasimod) indicated for ulcerative colitis; AND
6. Individual is not using the medication in combination with other biologic intended for treatment of ulcerative colitis, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
7. Individual does not have latent tuberculosis or serious active infection; AND
8. Must be dosed in accordance with the FDA label.  
 
CONTINUED APPROVAL for up to 1 year:
1. Individual has met initial criteria for a diagnosis of ulcerative colitis; AND
2. Individual has experienced a documented positive clinical response; AND
3. Individual is not using the medication in combination with other biologic intended for treatment of ulcerative colitis, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
4. Must be dosed in accordance with the FDA label.
 
PSORIATIC ARTHRITIS
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
1. Individual is greater than or equal to 18 years of age; AND
2. Individual has a diagnosis of moderate to severe psoriatic arthritis supported by the submitted medical records; AND
3. Individual has an active disease with documented inadequate response (trial of ≥3 months) to at least one conventional synthetic DMARDs (e.g., methotrexate, sulfasalazine, leflunomide) or phosphodiesterase 4 inhibitor (e.g., apremilast) (Ogdie, 2020); OR
4. Individual has an active disease with documented intolerance or contraindication to at least one conventional synthetic DMARDs (e.g., methotrexate, sulfasalazine, leflunomide) or phosphodiesterase 4 inhibitor (e.g., apremilast) (Ogdie, 2020); OR
5. Individual has previously received a biologic (e.g., etanercept, infliximab, ustekinumab, adalimumab, golimumab, certolizumab pegol, abatacept, secukinumab, ixekizumab, guselkumab) or oral Janus kinase inhibitor (e.g., tofacitinib, upadacitinib) indicated for psoriatic arthritis (Ogdie, 2020); OR
6. Individual has axial disease that is not responsive to treatment with NSAIDs, physiotherapy or sacroiliac joint glucocorticoid injections (GRAPPA, 2022); AND
7. Individual is not using the medication in combination with other biologic intended for treatment of psoriatic arthritis, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
8. Individual does not have latent tuberculosis or serious active infection; AND
9. Must be dosed in accordance with the FDA label.
 
CONTINUED APPROVAL for up to 1 year:
1. Individual has met criteria for initial approval; AND
2. Individual has experienced a documented positive clinical response; AND
3. Individual is not using the medication in combination with other biologic intended for treatment of psoriatic arthritis, including but not limited to: TNF inhibitor, IL-36 inhibitor, PDE4 inhibitor, any other IL inhibitor, or Janus kinase inhibitor; AND
4. Must be dosed in accordance with the FDA label.
 
PLAQUE PSORIASIS
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
1. Individual is greater than or equal to 18 years of age; AND
2. Individual has a diagnosis of moderate to severe plaque psoriasis established by or in consultation with a dermatologist as indicated by one of the following (AAD, 2019):   
a. Plaque psoriasis involving ≥3% body surface area (BSA) (Reich, 2017); OR   
b. Plaque psoriasis including areas that significantly impact daily function (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) (AAD, 2019); AND
3. Individual has an active disease with documented inadequate response (trial of ≥3 months) to phototherapy (e.g., UVB, PUVA) or at least one oral systemic treatment (e.g., methotrexate, cyclosporine, apremilast, acitretin); OR
4. Individual has an active disease with documented intolerance/contraindication to phototherapy (e.g., UVB, PUVA) or at least one oral systemic treatment (e.g., methotrexate, cyclosporine, apremilast, acitretin); OR
5. Individual has previously received a biologic (e.g., etanercept, infliximab, ustekinumab, adalimumab, certolizumab pegol, brodalumab, tildrakizumab, risankizumab, secukinumab, ixekizumab, guselkumab, alefacept, bimekizumab) or oral tyrosine kinase inhibitor (e.g., deucravacitinib) indicated for moderately to severely active plaque psoriasis (Menter, 2020); AND
6. Individual will not be using the medication in combination with any other biologic, including but not limited to: TNF inhibitor, PDE4 inhibitor, any IL inhibitor, or tyrosine kinase inhibitor; AND
7. Individual does not have latent tuberculosis or serious active infection; AND
8. Must be dosed in accordance with the FDA label.
 
CONTINUED APPROVAL for up to 1 year: 
1. Individual has met criteria for initial approval; AND
2. Individual has experienced a documented positive clinical response; AND
3. Individual is not using the medication in combination with any other biologic, including but not limited to: TNF inhibitor, PDE4 inhibitor, any IL inhibitor, or tyrosine kinase inhibitor; AND
4. Must be dosed in accordance with the FDA label.
 
Policy Guidelines
 
Ulcerative Colitis
Moderate to severe ulcerative colitis is characterized by the following:
1. Frequent stools (6 or more per day)
2. Frequent blood in stools
3. Frequent urgency
4. Hemoglobin <75% of normal
5. Erythropoietin Sedimentation Rate  >30
6. Elevated C-reactive protein
7. Fecal calprotectin >150-200
8. Ulcerative Colitis Endoscopic Index of Severity of 5-8
 
Ulcerative Colitis activity index according to American College of Gastroenterology:
1. Remission: daily formed stools, no blood in stool, no urgency, normal hemoglobin, < 30 erythrocyte sedimentation rate (ESR), normal C-reactive protein (CRP), < 150-000 fecal calprotectin (FC), 0-1 Ulcerative Colitis Endoscopic Index of Severity (UCEIS).
2. Mild: < 4 stools per day, intermittent bloody stools, occasional urgency, normal hemoglobin, < 30 ESR, elevated     CRP, >150-200 RC, 2-4 UCEIS.
3. Moderate - Severe: > 6  stools per day, frequent blood in stools, urgency often, < 75% of normal hemoglobin, > 30 ESR, elevated CRP, > 150-200 FC, 5-8 UCEIS.
 
Psoriatic Arthritis
Diagnosis of psoriatic arthritis is based on the Classification Criteria for Psoriatic Arthritis (CASPAR), which require presence of inflammatory articular disease (joint, spine or entheseal) AND at least two of the following:
1. Current psoriasis
2. Personal history of psoriasis
3. Family history of psoriasis in a first-or second- degree relative
4. Presence of psoriatic nail dystrophy (onycholysis, pitting and hyperkeratosis)
5. Rheumatoid factor negative
6. Current dactylitis or history of dactylitis recorded by a rheumatologist.
7. Juxtaarticular new bone formation on hand or foot x-ray.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
 
Plaque psoriasis disease activity according to Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics:
1. Mild: <3% BSA
2. Moderate: 3% - 10% BSA
3. Severe: >10% BSA, serious emotional consequences, or when it occurs in select locations, including but not restricted to, the hands, feet, scalp, face, or genital area, or when it causes intractable pruritus.
 
Dosage and Administration
Dosing per FDA Guidelines
 
The recommended dose of Ustekinumab is based on indication:
 
Plaque psoriasis adult subcutaneous injection:
1. The recommended dosage for an individual weighing less than or equal to 100 kg is 45 mg administered subcutaneously initially and 4 weeks later, followed by 45 mg administered subcutaneously every 12 weeks.
2. The recommended dosage for an individual weighing greater than 100 kg is 90 mg administered subcutaneously initially and 4 weeks later, followed by 90 mg administered subcutaneously every 12 weeks.
 
Plaque psoriasis pediatric subcutaneous injection:
1. The recommended dosage for an individual weighing less than 60 kg is 0.75 mg/kg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.
2. The recommended dosage for an individual weighing 60 kg to 100 kg is 45 mg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.
3. The recommended dosage for an individual weighing greater than 100 kg is 90 mg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.  
 
Psoriatic Arthritis subcutaneous injection:  
1. The recommended dosage is 45 mg administered subcutaneously initially and 4 weeks later, followed by 45 mg administered subcutaneously every 12 weeks.
2. For individuals with co-existent moderate-to-severe- plaque psoriasis weighing greater than 100 kg, the recommended dosage is 90 mg administered subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.
 
Psoriatic Arthritis – Pediatric (6 to 17 years old) subcutaneous injection:
1. The recommended dosage for a pediatric individual weighing less than 60 kg is 0.75 mg/kg subcutaneously.
2. The recommended dosage for a pediatric individual weighing 60 kg or more is 45 mg subcutaneously.
3. The recommended dosage for a pediatric individual weighing greater than 100 kg with co-existent moderate-to-severe plaque psoriasis is 90 mg subcutaneously.
 
Crohn’s Disease and Ulcerative Colitis initial adult intravenous infusion:
1. The recommended dosage for an individual weighing less than 55 kg is 260 mg in a single intravenous infusion.
2. The recommended dosage for an individual weighing 55kg to 85kg is 390 mg in a single intravenous infusion.
3. The recommended dosage for an individual weighing greater than 85 kg is 520 mg in a single intravenous infusion.
 
Crohn’s Disease and Ulcerative Colitis maintenance subcutaneous injection:
1. The recommended dosage is 90 mg administered subcutaneously 8 weeks after the initial intravenous dose, then every 8 weeks thereafter.   
 
Ustekinumab as:
    • Subcutaneous Injection:
        • Injection: 45 mg/0.5 mL or 90 mg/mL solution in a single-dose prefilled syringe.
        • Injection: 45 mg/0.5 mL solution in a single-dose vial.
    • Intravenous Infusion:
        • Injection: 130 mg/26 mL (5 mg/mL) solution in a single-dose vial.
 
Ustekinumab intravenous infusion (J3358) will only be available for a one-time initial infusion.
 
Ustekinumab intravenous infusion should be administered by a healthcare professional. In pediatric individuals, Ustekinumab subcutaneous injection should be administered by a healthcare professional.
 
Please refer to a separate policy on Site of Care or Site of Service Review policy #2018030 for pharmacologic/biologic medications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
The use of Ustekinumab, for any indication or circumstance not described above, does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for the following:
 
For members with contracts without primary coverage criteria, Ustekinumab, for any indication or circumstance not described above, is considered investigational including the following:
 
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective Prior to January 1, 2024
Meets Primary Coverage Criteria or Is Covered for Contracts Without Primary Coverage Criteria
 
The use of Ustekinumab meets primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when dosed in accordance with FDA approved labeling AND when all the following criteria are met based on diagnosis:
 
INITIAL APPROVAL STANDARD REVIEW for up to 12 months:
 
Plaque psoriasis
Individual is 6 years of age or older who have a diagnosis of moderate to severe Ps (≥3% BSA involvement) (Menter, 2018) OR involving sensitive areas or areas that significantly impact daily function (such as palms, soles of feet, head/neck, or genitalia) (Menter, 2018) AND
    1. Individual has previously met criteria for and received a FDA approved biologic indicated for the treatment of moderate to severe plaque psoriasis OR
    2. Individual has had an inadequate response to either phototherapy or a pharmacologic treatment with methotrexate, cyclosporine, or acitretin or has an intolerance or contraindication to phototherapy or all non-biologic pharmacologic treatment (methotrexate, cyclosporine, or acitretin) (Menter, 2018)
    3. Must be dosed in accordance wthi the FDA label.
 
Psoriatic arthritis
Individual 18 years of age or older has a diagnosis of moderate to severe PsA AND
    1. Individual has previously met criteria for and received a FDA approved biologic indicated for moderately to severely active psoriatic arthritis OR  
    2. Individual has had an inadequate response to conventional therapy [nonbiologic DMARDs (such as methotrexate, sulfasalazine, or leflunomide)] or an intolerance or contraindication to conventional therapy (Singh, 2018)
    3. Must be dosed in accordance with the FDA label.
 
Crohn’s disease
Individual 18 years of age or older has a diagnosis of moderately to severely active CD AND
    1. Individual has previously met criteria for and received a FDA approved biologic indicated for moderately to severely active Crohn’s disease OR  
    2. Individual has had an inadequate response to at least one conventional therapy option (i.e. azathioprine, mercaptopurine, sulfasalazine, methotrexate, or corticosteroids) or member has an intolerance or contraindication conventional therapy options (Lichtenstein, 2018)
    3. Must be dosed in accordance with the FDA label.
 
Ulcerative colitis
Individual 18 years of age or older has a diagnosis of moderately to severely active UC AND
    1. Individual  has previously met criteria for and received a FDA approved biologic indicated for moderately to severely active ulcerative colitis OR  
    2. Individual has had an inadequate response to at least one conventional therapy option (i.e. corticosteroids, azathioprine, or mercaptopurine) or individual has an intolerance or contraindication conventional therapy options(Rubin 2019)
    3. Must be dosed in accordance with the FDA label.
 
Continuation of therapy for 12 months:
 
    1. Individual meets criteria for initial approval based on indication.
    2. Individual has experienced a positive clinical response to ustekinumab.
    3. Dosed in accordance with FDA labeling.
 
Plaque psoriasis disease activity according to Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics:
 
Mild: <3% BSA
Moderate: 3% - 10% BSA
Severe: >10% BSA, serious emotional consequences, or when it occurs in select locations, including but not restricted to, the hands, feet, scalp, face, or genital area, or when it causes intractable pruritus.
 
Ulcerative Colitis activity index according to American College of Gastroenterology:
 
Remission: daily formed stools, no blood in stool, no urgency, normal hemoglobin, <30 erythrocyte sedimentation rate (ESR), normal C-reactive protein (CRP), <150-000 fecal calprotectin (FC), 0-1 Ulcerative Colitis Endoscopic Index of Severity (UCEIS)
Mild: <4 stools per day, intermittent bloody stools, occasional urgency, normal hemoglobin, <30 ESR, elevated     CRP, >150-200 RC, 2-4 UCEIS
Moderate - Severe: >6 stools per day, frequent blood in stools, urgency often, <75% of normal hemoglobin, >30 ESR, elevated CRP, >150-200 FC, 5-8 UCEIS
 
Dosage and Administration
Dosing per FDA Guidelines
 
The recommended dose of Ustekinumab is based on indication:
 
Plaque psoriasis adult subcutaneous injection:
    • Less than or equal to 100kg - 45mg administered subcutaneously initially and 4 weeks later, followed by 45mg administered subcutaneously every 12 weeks.
    • Greater than 100kg - 90mg administered subcutaneously initially and 4 weeks later, followed by 90mg administered subcutaneously every 12 weeks.
 
Plaque psoriasis pediatric subcutaneous injection:
    • Less than 60kg – 0.75mg/kg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.
    • 60kg to 100kg – 45mg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.
    • Greater than 100kg – 90mg subcutaneously initially and 4 weeks later, then every 12 weeks thereafter.  
 
Psoriatic Arthritis subcutaneous injection:  
    • 45mg administered subcutaneously initially and 4 weeks later, followed by 45mg administered subcutaneously every 12 weeks.
 
Psoriatic Arthritis – Pediatric (6 to 17 years old) subcutaneous injection:
    • Less than 60 kg – 0.75 mg/kg
    • 60 kg or more – 45 mg
    • Greater than 100 kg
 
Crohn’s Disease and Ulcerative Colitis initial adult intravenous infusion:
    • Less than 55kg – 260mg
    • 55kg to 85kg – 390mg
    • Greater than 85kg – 520 mg
 
Crohn’s Disease and Ulcerative Colitis maintenance subcutaneous injection:
    • 90mg administered subcutaneously 8 weeks after the initial intravenous dose, then every 8 weeks thereafter.  
 
Ustekinumab intravenous infusion (J3358) will only be available for a one-time initial infusion.
 
Ustekinumab intravenous infusion should be administered by a healthcare professional. In pediatric individuals, Ustekinumab subcutaneous injection should be administered by a healthcare professional.
 
Please refer to a separate policy on Site of Care or Site of Service Review policy #2018030 for pharmacologic/biologic medications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Ustekinumab does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for the following:
 
    1. Any other indications not included above: OR  
    2. In combination with TNF antagonists, JAK inhibitors, or other biologic drugs (such as, abatacept, anakinra, rituximab, or vedolizumab); OR  
    3. In combination with phototherapy OR
    4. If individual has tuberculosis, other active serious infections, or a history of recurrent infections; OR
    5. Individual has not had a tuberculin skin test (TST) or a Centers for Disease Control (CDC-) and Prevention -recommended equivalent to evaluate for latent tuberculosis prior to initiating Ustekinumab.
 
For members with contracts without primary coverage criteria, Ustekinumab does not meet member benefit certificate primary coverage criteria for the following:
 
    1. Any other indications not included above: OR  
    2. In combination with TNF antagonists, JAK inhibitors, or other biologic drugs (such as, abatacept, anakinra, rituximab, or vedolizumab); OR  
    3. In combination with phototherapy OR
    4. If individual has tuberculosis, other active serious infections, or a history of recurrent infections; OR
    5. Individual has not had a tuberculin skin test (TST) or a Centers for Disease Control (CDC-) and Prevention -recommended equivalent to evaluate for latent tuberculosis prior to initiating Ustekinumab.
 
 
For members with contracts without primary coverage criteria, the use of Ustekinumab for any indication or circumstance other than listed above is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Rationale:
The use of Ustekinumab for plaque psoriasis was studied in two multicenter, randomized, double-blind, placebo-controlled trials. Patients 18 years of age and older with plaque psoriasis were enrolled in the study. Patients had a minimum body surface area involvement of 10%, Psoriasis Area and Severity Index (PASI) score ≥ 12 and were candidates for phototherapy or systemic therapy. Study 1 enrolled 766 patients and study 2 enrolled 1,230 patients. Patients were randomized to receive placebo, 45mg, or 90mg of Ustekinumab. Ustekinumab patients received their doses at Weeks 0, 4, and 16. Placebo patients received placebo doses at Weeks 0 and 4 and then crossed over to receive either dose of Ustekinumab at Weeks 12 and 16. Subjects in all treatment groups had a median baseline PASI score ranging from approximately 17 to 18. Across both studies about 66% of all patients had received prior phototherapy and 69% had received either prior conventional systemic or biologic therapy. 28% of patients had a history of psoriatic arthritis. In Study 1, 66% of patients who received 90mg of Ustekinumab and 67% of patients who received 45mg of Ustekinumab achieved a PASI 75 response compared to 3% of patients who received placebo. In Study 2, 76% of patients who received 90mg Ustekinumab and 67% of patients who received 45mg of Ustekinumab achieved a PASI 75 response compared to 4% of patients who received placebo. In patients who weighed greater than 100kg, higher response rates were seen with 90mg dosing compared with 45mg dosing.
 
The use of Ustekinumab for plaque psoriasis in adolescent patients 12 and older was evaluated in a multicenter, randomized, double blind, placebo-controlled study. This study enrolled 110 patients 12 – 17 years of age with a minimum BSA involvement of 10%, a PASI score greater than or equal to 12, and a PGA score greater than or equal to 3, who were candidates for phototherapy or systemic therapy and whose disease was inadequately controlled by topical therapy. Patients were randomized to receive 0.75mg/kg Ustekinumab (patients weighing less than 60kg), 45mg Ustekinumab (patients weighing 60kg to 100kg), 90mg Ustekinumab (patients weighing greater than 100kg), or placebo at Weeks 0 and 4 followed by every 12 weeks thereafter. At Week 12, 80.6% of patients who had received Ustekinumab achieved a PASI 75 response compared to 10.8% of patients who received placebo.
 
The use of Ustekinumab for psoriatic arthritis was studied in two randomized, double-blind, placebo-controlled trials. 927 patients who were 18 years of age and older with active PsA despite NSAID or DMARD therapy were enrolled in the studies. Active PsA was defined as ≥5 swollen joints and ≥ tender joints. Patients with each subtype of PsA were enrolled, including patients with polyarticular arthritis, spondylitis with peripheral arthritis, asymmetric peripheral arthritis, distal interphalangeal involvement, and arthritis mutilans. Patients were randomized to receive 45mg Ustekinumab, 90mg Ustekinumab, or placebo subcutaneously at Weeks 0 and 4 followed by every 12 weeks thereafter. About 50% of patients continued stable doses of methotrexate. Study 1 did not allow patients who had previously been treated with TNF inhibitors. 58% of patients in Study 2 had previously been on TNF inhibitor therapy and over 70% of them discontinued their TNF inhibitor therapy due to lack of efficacy or intolerance. In both studies, a greater proportion of patients achieved ACR 20, ACR 50, and PASI 75 response in the Ustekinumab 45mg and 90mg groups compared to placebo at Week 24. Response were similar in patients despite prior TNF inhibitor therapy.
 
The use of Ustekinumab for Crohn’s Disease was evaluated in three randomized, double-blind, placebo-controlled clinical studies. Patients enrolled had moderately to severely active Crohn’s disease. Patients in Study 1 had failed or were intolerant to treatment with one or more TNF inhibitor. Patients in Study 2 had failed or were intolerant to treatment with immunomodulators or corticosteroids, but never failed treatment with a TNF inhibitor. Study 1 and Study 2 were two 8-week intravenous induction studies followed by a 44-week subcutaneous randomized withdrawal maintenance study (Study 3). In Study 1, 741 patients were included in the final efficacy analysis. In Study 2, 627 patients were included in the final efficacy analysis. In both studies, patients were randomized to receive a single intravenous infusion of Ustekinumab at either approximately 6mg/kg, placebo, or 130mg (a lower dose than recommended). In the two induction studies, a greater portion of patients treated with Ustekinumab, at the recommended dose of 6mg/kg dose, achieved clinical response at Week 6 and clinical remission at Week 8 compared to placebo. In Study 3, 388 patients were enrolled who achieved a clinical response at Week 8 with either induction dose of Ustekinumab in Studies 1 or 2. Patients were randomized to receive either a subcutaneous maintenance dose of 90mg Ustekinumab or placebo every 8 weeks for 44 weeks. At Week 44, 47% of patients who received Ustekinumab were corticosteroid-free and in clinical remission, compared to 30% of patients in the placebo group. For the patients who previously failed or were intolerant to TNF inhibitors, 61% of the Ustekinumab treated patients were in remission at Week 0 of Study 3 and 41% were in clinical remission at Week 44. In the placebo patients, 44% were in clinical remission at Week 0 and 26% of these patients were in clinical remission at Week 44. For the patients who had previously failed immunomodulator therapy or corticosteroids (but not TNF inhibitors), 64% of the Ustekinumab treated patients were in clinical remission at Week 0 of Study 3 and 63% were in remission at Week 44.  In the placebo patients, 71%% were in clinical remission at Week 0 and 44% were in clinical remission at Week 44.
 
The use of Ustekinumab for ulcerative colitis was evaluated in two randomized, double-blind, placebo-controlled clinical studies in adult patients with moderately to severely active ulcerative colitis who had an inadequate response to or failed to tolerate a biologic, corticosteroids, and/or mercaptopurine or azathioprine therapy. Study 1 was an 8-week intravenous induction study of Ustekinumab. Study 2 followed and was a 44-week subcutaneous randomized withdrawal maintenance study. Patients could continue other concomitant therapies such as aminosalicylates, immunomodulatory agents (AZA, 6-MP, or MTX), and oral corticosteroids. In Study 1, 961 patients were randomized to receive a single intravenous infusion of Ustekinumab 6mg/kg, 130mg (a lower dose than recommended), or placebo. The primary endpoint was clinical remission at Week 8. A significantly greater proportion of patients treated with 6mg/kg of Ustekinumab were in clinical remission and response and achieved endoscopic improvement and histologic-endoscopic mucosal improvement compared to placebo. In Study 2, 523 patients were evaluated who had achieved clinical response after the 8-week intravenous infusion. Patients were randomized to receive either a subcutaneous maintenance dose of 90mg Ustekinumab every 8 weeks, 90mg every 12 weeks, or placebo for 44 weeks. The primary endpoint was the proportion of patients in clinical remission at Week 44. 74% of patients who had received the recommended dose of 90mg Ustekinumab every 8 weeks were in clinical remission at Week 44 compared to 48% of patients who received placebo.
 
2022 Update
The IM-UNITI study and long-term extension (LTE) evaluated the long-term efficacy, safety, and immunogenicity of subcutaneous ustekinumab maintenance therapy in patients with Crohn's disease.
 
Patients completing safety and efficacy evaluations at week 44 of the maintenance study were eligible to participate in the LTE and continue the treatment they were receiving. Unblinding occurred after completion of maintenance study analyses (August 2015), and patients receiving placebo were discontinued from the study after unblinding. No dose adjustment occurred in the LTE. Efficacy assessments were conducted every 12 weeks until unblinding and at dosing visits thereafter through week 252. Serum ustekinumab concentrations and antidrug antibodies were evaluated through weeks 252 and 272, respectively.
 
Using an intent-to-treat analysis of all patients randomized to ustekinumab at maintenance baseline, 34.4% of patients in the every-8-weeks group and 28.7% in the every-12-weeks group were in clinical remission at week 252. Corresponding remission rates among patients who entered the LTE were 54.9% and 45.2%. Overall, adverse event rates (per 100 patient-years) from maintenance week 0 through the final visit generally were similar in the placebo and combined ustekinumab groups for all adverse events (440.3 vs 327.6), serious adverse events (19.3 vs 17.5), infections (99.8 vs 93.8), and serious infections (3.9 vs 3.4). Serum ustekinumab concentrations were maintained throughout the LTE. Antidrug antibodies occurred in 5.8% of patients who received ustekinumab during induction and maintenance and continued in the LTE.
 
Patients receiving subcutaneous ustekinumab maintained clinical remission through 5 years. No new safety signals were observed. ClinicalTrials.gov number NCT01369355. (Sandborn WJ, Rebuck R, Wang Y, et.al., 2021).
 
2023 Update
Rapid symptomatic relief is an important treatment goal for patients with ulcerative colitis (UC). A study was conducted to characterize early response with ustekinumab in patients with moderate-to-severe UC during the initial 16 weeks of treatment.
 
A post hoc analysis of data was conducted from A Study to Evaluate the Safety and Efficacy of Ustekinumab Induction and Maintenance Therapy in Participants With Moderately to Severely Active Ulcerative Colitis trial. Patients (N = 961) were randomized (1:1:1) to receive intravenous 130 mg ustekinumab, approximately 6 mg/kg ustekinumab, or placebo at week 0. Symptomatic remission, absolute stool number, Mayo stool frequency and rectal bleeding subscores, partial Mayo score, C-reactive protein, and fecal calprotectin were assessed in the overall population and for patients in the biologic-naïve or prior biologic failure subgroups.
 
A significantly greater percentage of patients in the 130-mg ustekinumab (20.0%; P = .015) or approximately 6-mg/kg ustekinumab (20.2%; P = .012) groups achieved symptomatic remission at week 2 vs placebo (12.9%). Mean [SD] changes from baseline in daily stool number on day 7 were greater in the ustekinumab groups (-1.1 [2.6] in 130 mg [P = .065] and -1.2 [2.5] in ∼6 mg/kg [P = .017]) vs placebo (-0.7 [2.7]). The percentage of patients with Mayo stool frequency subscore of 1 or less and rectal bleeding subscore of 0 increased from baseline through week 16 for both ustekinumab groups. Significant improvements in partial Mayo scores were observed by week 2 in both ustekinumab groups vs placebo (P ≤ .001). Significantly more patients in the ustekinumab groups had normalized C-reactive protein levels from week 2 to week 8 vs placebo (P ≤ .05). Similar results were observed with normalized fecal calprotectin levels between week 2 and week 4 (P ≤ .05).
 
Ustekinumab improved symptoms in patients with UC compared with placebo in as early as 7 days, indicating rapid onset of effect after induction. (Danese S, Sands BE, Abreu MT, et.al., 2022)
 
2024 Update
The FDA’s approval of ustekinumab for pediatric psoriatic arthritis is based on pharmacokinetic (PK) data and extrapolation of the established efficacy and existing safety profile of Stelara in multiple Phase 3 studies in adult and pediatric patients with moderate to severe plaque PsO (PSTELLAR, CADMUS, and CADMUS Jr) and adult patients with active PsA (PSUMMIT I and II). With the limited availability of pediatric PsA patients for inclusion in clinical trials, researchers utilized an extrapolation approach based on previous PK, efficacy, and safety observations from a closely adjacent population of pediatric patients with moderate to severe plaque PsO who also had active PsA, as well as adult patients with moderate to severe plaque PsO or active PsA. An analysis of the data demonstrated that PK exposure of Stelara in these pediatric PsO patients with active PsA was consistent with that of Phase 3 clinical trials of Stelara in pediatric PsO patients without active PsA, as well as with adult patients with moderate to severe plaque PsO or adult patients with active PsA, while data on common efficacy endpoints were similar in these pediatric PsO patients with active PsA. (Stelara, 2024)
CPT/HCPCS:
J3357Ustekinumab, for subcutaneous injection, 1 mg
J3358Ustekinumab, for intravenous injection, 1 mg
Q5137Injection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg
Q5138Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg
References: Coates LC, Soriano ER, Corp N, et al.(2022) Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): updated treatment recommendations for plaque psoriasis 2021. Nat Rev Rheumatol. 2022; Aug;18(8):465-79.

Danese S, Sands BE, Abreu MT, O'Brien CD, Bravatà I, Nazar M, Miao Y, Wang Y, Rowbotham D, Leong RWL, Arasaradnam RP, Afif W, Marano C.(2022) Early Symptomatic Improvement After Ustekinumab Therapy in Patients With Ulcerative Colitis: 16-Week Data From the UNIFI Trial. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2858-2867.e5. doi: 10.1016/j.cgh.2022.02.050. Epub 2022 Mar 8. PMID: 35276329.

Elmets CA, Korman NJ, Prater EF,(2021) Joint AAD–NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. Journal of the American Academy of Dermatology. 2021 Feb 1;84(2):432-70.

Feuerstein JD, Ho EY, Shmidt E, et. al.(2021) AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease. Gastroenterology. 2021 Jun 1;160(7):2496-508.

Helliwell PS, Taylor WJ.(2005) Classification and diagnostic criteria for psoriatic arthritis. Ann Rheum Dis. 2005;64 Suppl 2:ii3-8.

Lichtenstein GR, Loftus EV, Isaacs KL et al.(2018) 2018 American College of Gastroenterology Guideline for the management of Crohn’s disease in adults. Am J Gastroenterol 2018; 113:481–517.

Menter A, Gelfand JM, Connor C, et al.(2020) oint AAD-NPF guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol. 2020;82(6):1445-1486.

Menter A, Strober BE, Kaplan DH et al.(2018) Joint AAD-NPF Guidelines of Care for the Management and Treatment of Psoriasis with Biologics. Am Academy of Dermatology 2018; 80:1029-72.

Menter A, Strober BE, Kaplan DH, et. al.(2019) Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. Journal of the American Academy of Dermatology. 2019 Apr 1;80(4):1029-72.

Ogdie A, Coates LC, Gladman DD.(2020) Treatment guidelines in psoriatic arthritis. Rheumatology. 2020 Mar 1;59(Supplement_1):i37-46.

Raine T, Bonovas S, Burisch J, et. al.(2022) ECCO guidelines on therapeutics in ulcerative colitis: medical treatment. Journal of Crohn's and Colitis. 2022 Jan 1;16(1):2-17.

Rubin DT, Ananthakrishnan AN, Siegel CA et al.(2019) American College of Gastroenterology Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol 2019; 114:384-413.

Sandborn WJ, Gasink C, Gao LL et al.(2012) Ustekinumab Induction and Maintenance Therapy in Refractory Crohn's Disease. N Engl J Med. 2012 Oct 18;367(16):1519-28.

Sandborn WJ, Rebuck R, Wang Y, Zou B, Adedokun OJ, Gasink C, Sands BE, Hanauer SB, Targan S, Ghosh S, de Villiers WJS, Colombel JF, Feagan BG, Lynch JP(2022) Five-Year Efficacy and Safety of Ustekinumab Treatment in Crohn's Disease: The IM-UNITI Trial. Clin Gastroenterol Hepatol. 2022 Mar;20(3):578-590.e4. doi: 10.1016/j.cgh.2021.02.025. Epub 2021 Feb 19. PMID: 33618023; PMCID: PMC8374005.

Singh, Jasvinder A, et al.(2018) 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis & Rheumatology, 71(1), 2018, pp. 5–32.

Stelara [package insert], Horsham, PA. Janssen Biotech, Inc;

Ustekinumab: Stelara [package insert]. Horsham (PA): Janssen Biotech, 2022.

Van Rheenen PF, Aloi M, Assa A, et. al.(2021) The medical management of paediatric Crohn’s disease: an ECCO-ESPGHAN guideline update. Journal of Crohn's and Colitis. 2021 Feb 1;15(2):171-94.
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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