Does Q5138 require prior authorization?

Yes, Q5138 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5138?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`Q5138`, Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation of intolerance, contraindication, or adverse event to Steqeyma, Wezlana, or Yesintek when relying on intolerance/contraindication pathway for non-preferred product coverage.
Documentation of positive clinical response is required for continuation of therapy (per indication-specific continuation criteria).

Documentation of a trial of at least 14 weeks of Steqeyma, Wezlana, or Yesintek resulting in minimal clinical response to therapy and residual disease activity (required for Preferred Product Criteria exception to use non-preferred product).

Provider attestation (required in Preferred Product Criteria) that in their clinical opinion the clinical response would be expected to be superior with the requested non-preferred ustekinumab product than experienced with the preferred product (or attestation that the same intolerance/contraindication/adverse event would not be expected with the requested product).

For initial Crohn's disease and ulcerative colitis therapy: documentation that ustekinumab will be administered as a single intravenous induction dose consistent with FDA labeled dosing (and authorization will be for one induction dose).

Key Coverage Criteria

Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Moderately to severely active Crohn's disease (treatment proven) when all specified criteria in the Diagnosis-Specific Criteria are met.
Moderately to severely active ulcerative colitis (treatment proven) when all specified criteria in the Diagnosis-Specific Criteria are met.
Moderate to severe plaque psoriasis (treatment proven) when all specified criteria in the Diagnosis-Specific Criteria are met.
Psoriatic arthritis (treatment proven) when all specified criteria in the Diagnosis-Specific Criteria are met.
Adolescent patients (6 years or older) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (per FDA labeling; referenced in Clinical Evidence / FDA section).

16 Active Policies

MODA-USTEKINUMAB-622B4DD5F0, Ustekinumab: Stelara; Wezlana; Selarsdi; Pyzchiva; Otulfi; Imuldosa; Yesintek; Steqeyma; Starjemza; Ustekinumab-aekn§; Ustekinumab-ttwe§; Ustekinumab-aauz§; Ustekinumab-stba§; Ustekinumab§

EVICORE-MEDICAL_DRUG-77DEBEA86A94, Ustekinumab Intravenous (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Starjemza, Steqeyma, Wezlana, Yesintek, ustekinumab, ustekinumab-ttwe)

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UHC-POL-ustekinumab, Ustekinumab

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

BCBSIL-RX501.114, Ustekinumab and Associated Biosimilars

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSMT-RX501.114, Ustekinumab and Associated Biosimilars

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSNM-RX501.114, Ustekinumab and Associated Biosimilars

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.114, Ustekinumab and Associated Biosimilars

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

UMR-POL-UMR-ustekinumab, Ustekinumab

BCBSTN-d766e3ac4b, Ustekinumab Products: Ustekinumab (Stelara); Ustekinumab-auub (Wezlana); Ustekinumab-srlf (Imuldosa); Ustekinumab-aauz (Otulfi); Ustenkinumab-ttwe (Pyzchiva), Ustekinumab-aekn (Selarsdi); Ustenkinumab-stba (Steqeyma); Ustenkinumba-kfce (Yesintek); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustenkinumab-ttwe; Ustekinumab-hmny (Starjemza)

SUREST-POL-SUREST-ustekinumab, Ustekinumab

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Q5138, Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg