Otulfi SC — Medica
any indication meeting the standard Inflammatory Conditions – Ustekinumab Subcutaneous Products Prior Authorization Policy with Dosing
Preferred products
- Stelara SC
- Imuldosa SC
- Selarsdi SC
- ustekinumab-ttwe SC
- Yesintek SC
Initial criteria
- Patient meets the standard Inflammatory Conditions – Ustekinumab Subcutaneous Products Prior Authorization Policy with Dosing criteria; AND
- Patient has tried ALL of Stelara, Imuldosa, Selarsdi, ustekinumab-ttwe, and Yesintek subcutaneous [documentation required]; AND
- Patient cannot continue to use ALL Preferred medications (i.e., Stelara, Imuldosa, Selarsdi, ustekinumab-ttwe, and Yesintek subcutaneous) due to formulation differences in the inactive ingredient(s) (e.g., stabilizing agent, buffering agent, and/or surfactant) which, according to the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Approval duration
same as standard Inflammatory Conditions – Ustekinumab Subcutaneous Products Prior Authorization Policy with Dosing