Limited Coverage Drugs - Ustekinumab

Generic Name / Strength / Form

ustekinumab

Criteria

Approval Period

Treatment of moderate to severe psoriasis, according to established criteria*, when prescribed by a dermatologist

Initial: 3 doses
Renewal: one year

Practitioner Exemptions

  • None

Special Notes

  • Coverage for psoriasis became effective November 30, 2009.

Special Authority Request Form(s)

* Click on the appropriate Special Authority Form below for full criteria: