UnitedHealthcare Ustekinumab (Stelara) prior authorization requirements (2026)
What UnitedHealthcare generally requires to approve Ustekinumab (Stelara) (CPT J3357, J3358), for Commercial plans. Yes. UnitedHealthcare generally requires prior authorization for Ustekinumab (Stelara) (CPT J3357, J3358).
Medical-necessity criteria UnitedHealthcare generally applies
Prior authorization required. Preferred products: Starjemza, Steqeyma, Wezlana, Yesintek; brand Stelara and several biosimilars are non-preferred and require preferred-product exception criteria. CROHN'S DISEASE: moderately-to-severely active disease AND one of - failure to one conventional therapy (corticosteroids, 6-mercaptopurine, azathioprine, methotrexate) at maximally indicated doses unless contraindicated, OR prior treatment with a CD-approved targeted immunomodulator. ULCERATIVE COLITIS: moderately-to-severely active disease AND one of - prior/concurrent inadequate response to oral corticosteroids and/or immunosuppressants, OR prior UC-approved targeted immunomodulator, OR currently on ustekinumab. Prescribed by/with a gastroenterologist. Dosing: single IV induction per FDA labeling, then subcutaneous maintenance 8 weeks later and every 8 weeks. Initial authorization = one induction dose; continuation up to 12 months with documented positive clinical response.
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 UnitedHealthcare policy.
Commonly required documentation
- Diagnosis
- documented conventional-therapy or prior-targeted-immunomodulator history
- specialist prescriber
- FDA-compliant dosing
- response documentation for continuation.
Situations to verify before submitting
UnitedHealthcare may not cover Ustekinumab (Stelara) in these situations. Verify against the current policy rather than assuming a denial:
- Not received in combination with a systemic targeted immunomodulator for the same indication
How to submit
- Method: UnitedHealthcare provider portal (medical benefit drug review)
- Portal: UnitedHealthcare Provider Portal
Source
Source: UHC Commercial Medical Benefit Drug Policy 2026D0045AA Ustekinumab (eff 2026-06-01). Codes J3357 (SC), J3358 (IV). Last verified 2026-06-17.
Frequently asked questions
Does UnitedHealthcare require prior authorization for Ustekinumab (Stelara)?
Yes. UnitedHealthcare generally requires prior authorization for Ustekinumab (Stelara) (CPT J3357, J3358).
What does UnitedHealthcare require to approve Ustekinumab (Stelara)?
Prior authorization required. Preferred products: Starjemza, Steqeyma, Wezlana, Yesintek; brand Stelara and several biosimilars are non-preferred and require preferred-product exception criteria. CROHN'S DISEASE: moderately-to-severely active disease AND one of - failure to one conventional therapy (corticosteroids, 6-mercaptopurine, azathioprine, methotrexate) at maximally indicated doses unless … Always confirm against the current UnitedHealthcare policy.
How long does a UnitedHealthcare prior authorization take?
Turnaround varies by plan and submission method. Check the UnitedHealthcare portal for current timeframes.
Submitting Ustekinumab (Stelara) to UnitedHealthcare?
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.