Q5099, Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of intolerance, contraindication, or adverse event to Steqeyma, Wezlana, or Yesintek when relying on intolerance/contraindication pathway for non-preferred product coverage.
- Documentation of positive clinical response is required for continuation of therapy (per indication-specific continuation criteria).
- When prior targeted immunomodulator therapy is cited as meeting criteria, documentation is required (policy: 'Document drug, date, and duration of therapy').
- Documentation of a trial of at least 14 weeks of Steqeyma, Wezlana, or Yesintek resulting in minimal clinical response to therapy and residual disease activity (required for Preferred Product Criteria exception to use non-preferred product).
Key Coverage Criteria
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
- Moderately to severely active Crohn's disease (treatment proven) when all specified criteria in the Diagnosis-Specific Criteria are met.
- Moderately to severely active ulcerative colitis (treatment proven) when all specified criteria in the Diagnosis-Specific Criteria are met.
- Moderate to severe plaque psoriasis (treatment proven) when all specified criteria in the Diagnosis-Specific Criteria are met.
- Psoriatic arthritis (treatment proven) when all specified criteria in the Diagnosis-Specific Criteria are met.
- Adolescent patients (6 years or older) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (per FDA labeling; referenced in Clinical Evidence / FDA section).
14 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UHC-POL-ustekinumab, Ustekinumab
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSIL-RX501.114, Ustekinumab and Associated Biosimilars
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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