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Stelara® (Ustekinumab) – Commercial Medical Benefit Drug

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Stelara® (Ustekinumab) – Commercial Medical Benefit Drug UnitedHealthcare® Commercial Medical Benefit Drug Policy Stelara® (Ustekinumab) Policy Number: 2021D0045T Effective Date: September 1, 2021 Instructions for Use Table of Contents Page Related Commercial Policies Coverage Rationale ....................................................................... 1 • Maximum Dosage Applicable Codes .......................................................................... 6 • Provider Administered Drugs – Site of Care Background.................................................................................... 9 • Self-Administered Medications Benefit Considerations .................................................................. 9 Clinical Evidence ........................................................................... 9 Community Plan Policy U.S. Food and Drug Administration ........................................... 15 • Stelara® (Ustekinumab) References ................................................................................... 15 Policy History/Revision Information ........................................... 17 Instructions for Use ..................................................................... 18 Coverage Rationale See Benefit Considerations This policy refers to Stelara (ustekinumab) injection. Stelara (ustekinumab) for self-administered subcutaneous injection is obtained under the pharmacy benefit. Stelara is proven for the treatment of Crohn’s disease when all of the following criteria are met: Diagnosis of moderately to severely active Crohn’s disease; and One of the following: o For initial therapy, all of the following: . Stelara is to be administered as a single intravenous induction dose; and . Stelara induction dosing is in accordance with the United States Food and Drug Administration approved labeled dosing for Crohn’s disease; and . Patient is not receiving Stelara in combination with either of the following: Biologic DMARD [e.g., infliximab, Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] Janus kinase inhibitor [e.g., Xeljanz (tofacitinib), Olumiant (baricitinib)]16 and . Authorization will be for one induction dose. o For continuation of therapy, all of the following: . Documentation of positive clinical response; and . Prescriber attestation that the patient or caregiver are not able to be trained or are physically unable to administer Stelara FDA labeled for self-administration; prescriber must submit explanation; and . Stelara is to be subcutaneously administered 8 weeks after the initial intravenous dose; and . Stelara continuation dosing is in accordance with the United States Food and Drug Administration approved labeled dosing for Crohn’s disease; and . Patient is not receiving Stelara in combination with either of the following: Biologic DMARD [e.g., infliximab, Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] Janus kinase inhibitor [e.g., Xeljanz (tofacitinib), Olumiant (baricitinib)]16 and Stelara® (Ustekinumab) Page 1 of 18 UnitedHealthcare Commercial Medical Benefit Drug Policy Effective 09/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Authorization is for no more than 12 months. Stelara is medically necessary for the treatment of Crohn’s disease when all of the following criteria are met: Diagnosis of moderately to severely active Crohn’s disease; and One of the following: o For initial therapy, all of the following: . One of the following: • History of failure to one of the following conventional therapies at up to maximally indicated doses, unless contraindicated or clinically significant adverse effects are experienced o Corticosteroids (e.g., prednisone, methylprednisolone, budesonide) o 6-mercaptopurine (Purinethol) o Azathioprine (Imuran) o Methotrexate (Rheumatrex, Trexall) or • Patient has been previously treated with a biologic DMARD FDA-approved for the treatment of Crohn’s disease [e.g., Cimzia (certolizumab), Humira (adalimumab)] and . Stelara is to be administered as a single intravenous induction dose; and . Stelara induction dosing is in accordance with the United States Food and Drug Administration approved labeled dosing for Crohn’s disease; and . Patient is not receiving Stelara in combination with either of the following: Biologic DMARD [e.g., infliximab, Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] Janus kinase inhibitor [e.g., Xeljanz (tofacitinib), Olumiant (baricitinib)]16 and . Prescribed by or in consultation with a gastroenterologist; and . Authorization will be for one induction dose. o For continuation of therapy, all of the following: . Documentation of positive clinical response; and . Prescriber attestation that the patient or caregiver are not able to be trained or are physically unable to administer Stelara FDA labeled for self-administration; prescriber must submit explanation; and . Stelara is to be subcutaneously administered 8 weeks after the initial intravenous dose; and . Stelara continuation dosing is in accordance with the United States Food and Drug Administration approved labeled dosing for Crohn’s disease; and . Patient is not receiving Stelara in combination with either of the following: Biologic DMARD [e.g., infliximab, Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] Janus kinase inhibitor [e.g., Xeljanz (tofacitinib), Olumiant (baricitinib)]16 and . Authorization is for no more than 12 months. Stelara is proven for the treatment of plaque psoriasis when all of the following criteria are met: For initial therapy, all of the following: o Diagnosis of moderate to severe plaque psoriasis; and o Patient is a candidate for phototherapy or systemic therapy; and o Prescriber attestation that the patient or caregiver are not able to be trained or are physically unable to administer Stelara FDA labeled for self-administration; prescriber must submit explanation; and o Stelara is initiated and titrated according to US Food and Drug Administration labeled dosing for plaque psoriasis; and o Patient is not receiving Stelara in combination with any of the following: . Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] . Janus kinase inhibitor [e.g., Xeljanz (tofacitinib), Olumiant (baricitinib)]16 . Phosphodiesterase 4 (PDE4) inhibitor [e.g., Otezla (apremilast)] and o Initial authorization is for no more than 12 months. For continuation of therapy, all of the following: Stelara® (Ustekinumab) Page 2 of 18 UnitedHealthcare Commercial Medical Benefit Drug Policy Effective 09/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. o Documentation of positive clinical response; and o Prescriber attestation that the patient or caregiver are not able to be trained or are physically unable to administer Stelara FDA labeled for self-administration; prescriber must submit explanation; and o Stelara is initiated and titrated according to US Food and Drug Administration labeled dosing for plaque psoriasis; and o Patient is not receiving Stelara in combination with any of the following: . Biologic DMARD [e.g., infliximab, Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] . Janus kinase inhibitor [e.g., Xeljanz (tofacitinib), Olumiant (baricitinib)]16 . Phosphodiesterase 4 (PDE4) inhibitor [e.g., Otezla (apremilast)] and o Authorization is for no more than 12 months. Stelara is medically necessary for the treatment of plaque psoriasis when all of the following criteria are met: For initial therapy, all of the following: o Diagnosis of moderate to severe plaque psoriasis; and o One of the following: . All of the following: Greater than or equal to 3% body surface area involvement, palmoplantar, facial, genital involvement, or severe scalp psoriasis; and History of failure to one of the following topical therapies, unless contraindicated or clinically significant adverse effects are experienced: • Corticosteroids (e.g., betamethasone, clobetasol, desonide) • Vitamin D analogs (e.g., calcitriol, calcipotriene) • Tazarotene • Calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) • Anthralin • Coal tar and History of failure to a 3 month trial of methotrexate at the maximally indicated dose, unless contraindicated or clinically significant adverse effects are experienced or . Patient has been previously treated with a biologic DMARD FDA-approved for the treatment of plaque psoriasis [e.g., Cimzia (certolizumab), Humira (adalimumab), Skyrizi (risankizumab-rzaa), Tremfya (guselkumab)]; or . Patient is currently on Stelara and o Prescriber attestation that the patient or caregiver are not able to be trained or are physically unable to administer Stelara FDA labeled for self-administration; prescriber must submit explanation; and o Stelara is initiated and titrated according to US Food and Drug Administration labeled dosing for plaque psoriasis; and o Patient is not receiving Stelara in combination with any of the following: . Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] . Janus kinase inhibitor [e.g., Xeljanz (tofacitinib), Olumiant (baricitinib)]16 . Phosphodiesterase 4 (PDE4) inhibitor [e.g., Otezla (apremilast)] and o Prescribed by or in consultation with a dermatologist; and o Initial authorization is for no more than 12 months. For continuation of therapy, all of the following: o Documentation of positive clinical response; and o Prescriber attestation that the patient or caregiver are not able to be trained
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