Limited coverage criteria – ustekinumab for psoriatic arthritis

 

Return to Special Authority drug list

Generic name		ustekinumab
Brand	Strength	Form
Otulfi®	45 mg/0.5 mL	pre-filled, single-use syringe for subcutaneous injection
	90 mg/1 mL	pre-filled, single-use syringe for subcutaneous injection
Jamteki™	45 mg/0.5 mL	pre-filled, single-use syringe for subcutaneous injection
	90 mg/1 mL	pre-filled, single-use syringe for subcutaneous injection
Pyzchiva®	45 mg/0.5 mL	pre-filled, single-use syringe for subcutaneous injection
	90 mg/1 mL	pre-filled, single-use syringe for subcutaneous injection
Steqeyma®	45 mg/0.5 mL	pre-filled, single-use syringe for subcutaneous injection
	90 mg/1 mL	pre-filled, single-use syringe for subcutaneous injection
Wezlana™	45 mg/0.5 mL	pre-filled, single-use syringe for subcutaneous injection
	45 mg/0.5 mL	pre-filled, single-use autoinjector for subcutaneous injection
	90 mg/1 mL	pre-filled, single-use syringe for subcutaneous injection
Yesintek™	45 mg/0.5 mL	pre-filled, single-use syringe for subcutaneous injection
	90 mg/1 mL	pre-filled, single-use syringe for subcutaneous injection

Special Authority criteria	Approval period
For the treatment of adult patients with active psoriatic arthritis (PsA) according to established criteria1 when a Special Authority request is submitted by a rheumatologist.	Initial approval: 1 year Renewal: 1 year

Practitioner exemptions

• None

Special notes

• ¹Established criteria are explained in the Special Authority forms below
• PharmaCare coverage will not be provided for ustekinumab in combination with other biologic drugs or a janus kinase (JAK)-inhibitor for the treatment of PsA
• PharmaCare covers a maximum 84-day supply per fill of ustekinumab

Special Authority request form(s)

• Log in to eForms
• HLTH 5360 – Targeted DMARDs for Psoriatic Arthritis: Initial/Switch (PDF, 812KB)
• HLTH 5361 – Targeted DMARDs for Psoriatic Arthritis: Renewal/Dosing Adjustment (PDF, 856KB)
• HLTH 5364 – Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (PDF, 64KB)
• HLTH 5383 – Health Assessment Questionnaire (HAQ) (PDF, 528KB)