Aetna Ustekinumab (Stelara) prior authorization requirements (2026)
What Aetna generally requires to approve Ustekinumab (Stelara) (CPT J3357, J3358), for Commercial plans. Yes. Aetna generally requires prior authorization for Ustekinumab (Stelara) (CPT J3357, J3358).
Medical-necessity criteria Aetna generally applies
Precertification required. Brand-selection step: branded ustekinumab is medically necessary only for members with a contraindication, intolerance, or ineffective response (one-month trial each) to all of Entyvio, Skyrizi, Stelara, Tremfya, and one of Avsola/Inflectra/Renflexis. Crohn's disease or ulcerative colitis: moderately-to-severely active disease, prescribed by/with a gastroenterologist. Dosing: weight-based single IV induction (55 kg or less = 260 mg; over 55-85 kg = 390 mg; over 85 kg = 520 mg) then 90 mg subcutaneously at 8 weeks and every 8 weeks. Continuation (12 months) requires documented positive clinical response or remission (CD: abdominal pain, diarrhea, weight, endoscopic appearance; UC: stool frequency, rectal bleeding, urgency, CRP/fecal calprotectin, endoscopy).
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Ustekinumab (Stelara). Confirm the covered diagnosis list against the current Aetna policy.
Commonly required documentation
- Diagnosis (moderate-to-severe CD or UC)
- brand-selection step documentation
- weight for IV induction dosing
- specialist prescriber
- response measures for continuation.
Situations to verify before submitting
Aetna may not cover Ustekinumab (Stelara) in these situations. Verify against the current policy rather than assuming a denial:
- Cannot be used concomitantly with any other biologic or targeted synthetic drug for the same indication
How to submit
- Method: Aetna precertification (Availity)
- Portal: Availity
Source
Source: Aetna CPB 0912 Ustekinumab. Codes J3357 (SC), J3358 (IV). Effective/review date not captured from the page render. Last verified 2026-06-17.
Frequently asked questions
Does Aetna require prior authorization for Ustekinumab (Stelara)?
Yes. Aetna generally requires prior authorization for Ustekinumab (Stelara) (CPT J3357, J3358).
What does Aetna require to approve Ustekinumab (Stelara)?
Precertification required. Brand-selection step: branded ustekinumab is medically necessary only for members with a contraindication, intolerance, or ineffective response (one-month trial each) to all of Entyvio, Skyrizi, Stelara, Tremfya, and one of Avsola/Inflectra/Renflexis. Crohn's disease or ulcerative colitis: moderately-to-severely active disease, prescribed by/with a gastroenterologist. Do… Always confirm against the current Aetna policy.
How long does a Aetna prior authorization take?
Turnaround varies by plan and submission method. Check the Aetna portal for current timeframes.
Submitting Ustekinumab (Stelara) to Aetna?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.