Does Medicare Cover STELARA?
- Learn whether Medicare plans will cover STELARA, a prescription drug used to treat psoriasis, psoriatic arthritis, ulcerative colitis and Chron's disease.
People with psoriasis, psoriatic arthritis, ulcerative colitis and Crohn's disease may want to use STELARA for treatment. However, STELARA is a relatively expensive medication, and there are no generic alternatives available at this time.
Fortunately, some Medicare plans do cover STELARA. Only 9.1% of Medicare beneficiaries have no drug coverage, so it's likely your plan offers some assistance. To see for sure whether your plan will cover STELARA, you can check the formulary, a list each plan has which details the prescription drugs it covers.
Basic Drug Information About STELARA
STELARA contains the active ingredient ustekinumab. It is administered by IV or by subcutaneous injection into fatty parts of the skin, such as the upper arms, buttock, thighs or abdomen. The drug treats Crohn's disease, psoriasis and psoriatic arthritis by binding to and reducing inflammatory substances in the body. Major side effects include weakness, fatigue, headache, vomiting, irritation at the injection site and nose and throat irritation.
For treatment of psoriasis or psoriatic arthritis, you receive an initial subcutaneous injection followed by a second dose 4 weeks later. After that, you receive a dose every 3 months. To treat Crohn's disease or ulcerative colitis, the first dose is administered via injection into a vein. Then, doses are given every 8 weeks as directed by a doctor.
How Much Does STELARA Cost With Medicare?
If your Medicare plan covers STELARA, what it covers and what you pay depends on whether you're in the deductible or copay stage. A deductible is the amount of money you are required to pay before Medicare begins covering costs. If you have not yet met your deductible, you will be responsible for the drug's full cost up to your deductible amount. In 2022, deductibles for Medicare prescription drug plans may not exceed $480, and your deductible could be as low as $0.
Once your deductible is met, you enter the copay, or initial coverage, stage. During this stage, you are responsible for either a flat fee or a percentage of your covered medications, depending on your plan.
Does Medicare Have Any Restrictions on Coverage?
Some Medicare plans do place quantity limits on STELARA or require prior authorization. A quantity limit only allows you to fill a prescription for a limited amount of the drug at a time. Prior authorization requires your doctor to contact your plan and show that the drug is medically necessary before you can receive it.