More topics

Limited coverage criteria – ustekinumab for plaque psoriasis

Last updated on March 25, 2025

 

Return to Special Authority drug list

Generic name:

 ustekinumab

Brand name

Strength

Form

Jamteki™

 45 mg/0.5 mL pre-filled syringe
90 mg/1 mL
Wezlana™ 45 mg/0.5 mL pre-filled syringe
single-use vial
90 mg/1 mL pre-filled syringe
Steqeyma® 45 mg/0.5 mL pre-filled syringe
90 mg/1 mL

Special Authority criteria

Approval period

Initial

For the treatment of chronic moderate to severe plaque psoriasis in adult patients (18 years of age and older) who meet the following conditions: 

  •  Patient has a body surface area (BSA) involvement of >10% and/or significant involvement of the face, hands, feet, or genital region

AND

  • Patient failed to respond, is intolerant, or is unable to access UV phototherapy

AND 

  • Patient has a baseline pre-biologic psoriasis area severity index (PASI) of ≥ 12 

AND

  •  Patient has had treatment failure1, intolerance, or a contraindication to methotrexate AND cyclosporine

AND 

  • Special Authority request submitted by a dermatologist

16 weeks

Initial renewal

  • Patient has maintained a PASI of ≥ 75 from the baseline biologic naive PASI score

AND

  • Special Authority request submitted by a dermatologist

1 year

Second and subsequent renewals

  • Patient has maintained a PASI of ≥ 50 from the baseline biologic naive PASI score

AND

  • Special Authority request submitted by a dermatologist

1 year

Practitioner exemptions

  • None

Special notes

  • 1For treatment failure, an adequate trial is considered to be a continuous 3-month trial of methotrexate at a dose of 20 mg weekly (15 mg weekly for ages >65), AND cyclosporine 4 mg/kg/day
  • PharmaCare coverage will not be provided for ustekinumab in combination with other biologic drugs for the treatment of PsO in adults
  • PharmaCare covers a maximum 84-day supply per fill of ustekinumab
  • Additional information expected to assist with processing of coverage requests is detailed on the forms linked below (and on the eForms published online)

Special Authority request form(s)