Ustekinumab — United Healthcare

Crohn’s Disease (CD)

Initial criteria

Diagnosis of moderately to severely active Crohn’s disease 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, Skyrizi (risankizumab), Tremfya (guselkumab), Cosentyx (secukinumab), Taltz (ixekizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)] for 90 mg/1 mL dose (maintenance dosing)

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 [same list]

12 months