ustekinumab — United Healthcare

Initial criteria

• Diagnosis of moderate to severe plaque psoriasis
• One of the following: (a) All of the following: i. ≥ 3% body surface area involvement, palmoplantar, facial, genital involvement, or severe scalp psoriasis AND ii. History of failure to one of the following topical therapies unless contraindicated or clinically significant adverse effects: corticosteroids (e.g., betamethasone, clobetasol, desonide), vitamin D analogs (e.g., calcitriol, calcipotriene), tazarotene, calcineurin inhibitors (e.g., tacrolimus, pimecrolimus), anthralin, coal tar AND iii. History of failure to a 3‑month trial of methotrexate at maximally indicated dose unless contraindicated or experienced adverse effects OR (b) Previously treated with a targeted immunomodulator FDA‑approved for plaque psoriasis (e.g., Cimzia (certolizumab), adalimumab, Otezla (apremilast), Skyrizi (risankizumab), Tremfya (guselkumab)) OR (c) Both of the following: i. Currently on requested ustekinumab product as documented by claims or records AND ii. Has not received manufacturer free sample or assistance to establish as current user
• Patient not receiving ustekinumab 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), Siliq (brodalumab), Ilumya (tildrakizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]
• Prescribed by or in consultation with a dermatologist

Reauthorization criteria

• Documentation of positive clinical response to ustekinumab therapy
• Not receiving ustekinumab in combination with another targeted immunomodulator [same list as above]

Approval duration

12 months