ustekinumab — United Healthcare

Crohn’s disease

Initial criteria

Diagnosis of moderately to severely active Crohn’s disease
AND one of the following: (a) Patient has been established on therapy with the requested ustekinumab product under an active UnitedHealthcare medical benefit prior authorization for treatment of moderately to severely active Crohn’s disease OR (b) BOTH: i. Patient is currently on the requested ustekinumab product therapy for moderately to severely active Crohn’s disease as documented by claims history or submission of medical records (document date and duration of therapy) AND ii. Patient has not received a manufacturer supplied sample at no cost in the prescriber’s office, or any form of assistance from a manufacturer sponsored program (e.g., sample card redeemable for free supply)
AND Patient is not receiving the requested ustekinumab product in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Skyrizi (risankizumab)]
AND Prescribed by or in consultation with a gastroenterologist

Documentation of positive clinical response to the requested ustekinumab therapy
AND Patient is not receiving the requested ustekinumab product in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Skyrizi (risankizumab)]

12 months