Does Medicare Part B cover ustekinumab (Stelara)?

Medicare Part B is outpatient medical insurance that offers some outpatient prescription drug coverage. This is usually for medication that someone cannot administer themselves and needs to be administered in an outpatient hospital setting or a doctor’s office.

Before 2023, Medicare Part B covered subcutaneous versions of Stelara, which a physician had to inject into someone’s skin. However, Medicare Administrative Contractors now consider Stelara a self-administered drug, excluding it from Part B coverage.

Medicare Part D plans cover Stelara, but people can check an individual plan’s formulary (list of drugs) for more information. These plans may divide drugs into different tiers.

On top of typical payments, such as monthly premiums and a yearly deduction, Part D prescription coverage costs may vary depending on:

• the person’s prescription
• whether the drug is on the drug list or the plan covers it as an exception
• the tier
• whether someone has met their deductible or out-of-pocket limits
• the pharmacy someone uses
• whether someone qualifies for Medicare Extra Help

A report by the Office of Inspector General found that, in 2021, Stelara cost 80% more annually per enrollee under Medicare Part D than Part B. Since Part B stopped offering coverage, some people experienced higher out-of-pocket costs.

However, the 2022 Inflation Reduction Act allows Medicare to directly negotiate prescription drug costs. Stelara was one of the first 10 drugs the Centers for Medicare & Medicaid Services (CMS) chose for negotiation in August 2023.

CMS negotiated a 66% discount for Stelara from the 2021 price list, though the newly negotiated prices will not go into effect until 2026.

However, starting in 2025, all Medicare plans will cap out-of-pocket prescription drug costs to $2,000. This means that if someone’s out-of-pocket payments reach $2,000, they qualify for “catastrophic coverage” and will not have to pay any more out-of-pocket costs that year.

People can speak with their prescription provider and look at their Part D plan details to learn whether it covers Stelara and how much they may need to pay out of pocket.