Does Medicare cover Stelara?
Medicare is a government-funded program that gives healthcare coverage to people 65 or older. People under 65 may be eligible for Medicare if they have certain disabilities or have medical conditions such as end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig’s disease.
There are 4 parts to Medicare: A, B, C, and D:
- Part A is hospital insurance. It covers inpatient care, skilled nursing facility stays, hospice care, and some home healthcare.
- Part B is medical insurance. It covers doctor visits, outpatient services, and medications administered by your healthcare provider.
- Part C, also called Medicare Advantage, is offered by private insurers and bundles Part A, Part B, and usually Part D. You generally use in-network providers.
- Part D is prescription drug coverage. It helps cover the cost of prescription medications and certain vaccines.
Medicare beneficiaries, individuals soon to be eligible, and those advising on their behalf can visit Medicare.gov for plan and coverage details.
Stelara (ustekinumab) is an expensive biologic medication with no generic available, approved to treat plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn’s disease. A biosimilar, Wezlana (ustekinumab‑auub), was recently approved and may be interchangeable and more affordable once available.
Does Medicare cover the cost of Stelara? According to GoodRx, 79% of Medicare prescription drug plans include Stelara on their formularies. However, your out‑of‑pocket cost varies by coverage stage:
- Deductible stage: you may pay the full cost, often over $30,000 per dose.
- Post‑Deductible (Initial Coverage): copays range from around $7,500 to over $30,000 per dose.
- Coverage Gap (Donut Hole): copays range from about $14,000 to over $30,000.
- Catastrophic Coverage (Post‑Donut Hole): you could pay as little as $10 per dose.
Some Part D plans impose quantity limits or require prior authorization for Stelara. Your provider must demonstrate medical necessity. Check your specific plan formulary and cost-sharing details.
Read on for more information about Stelara and frequently asked questions.
Stelara FAQs
What does Stelara treat?
Stelara (ustekinumab) is FDA-approved for:
- Adults with moderate to severe plaque psoriasis
- Adults with active psoriatic arthritis
- Adults with moderate to severe active ulcerative colitis
- Adults with moderate to severe active Crohn’s disease
- Children 6 years and older with moderate to severe plaque psoriasis or active psoriatic arthritis
How does Stelara work?
Ustekinumab is a monoclonal antibody that inhibits interleukin‑12 (IL‑12) and interleukin‑23 (IL‑23), proteins involved in inflammation. By blocking these, Stelara reduces inflammatory symptoms.
How is Stelara administered?
Dosage and route depend on condition:
- Crohn’s disease and ulcerative colitis: initial IV infusion, then subcutaneous injection every 8 weeks (thigh, buttock, or abdomen).
- Psoriasis and psoriatic arthritis (ages 6+): subcutaneous injection, initial dose, second dose at week 4, then every 12 weeks (rotate sites).
Avoid injecting into red, tender, hard, or bruised skin. Rotate injection sites each dose.
What drug interactions are there with Stelara?
Ask your provider if medications, OTC drugs, vitamins, or supplements you take may interact, including warfarin, live vaccines (eg, BCG), and cyclosporine.
What are the side effects of Stelara?
Common side effects include:
- Cold symptoms (runny/stuffy nose, sore throat)
- Infections (bronchitis, sinusitis, UTI, yeast infection)
- Injection site reactions
- Headache, tiredness, nausea, itchiness, vomiting
Other possible effects:
- Back pain, dizziness, depression, muscle pain, diarrhea
Rare serious effects:
- Anaphylaxis (hives, facial/tongue/throat swelling, shortness of breath)
- Serious infections (eg, tuberculosis)
- Increased cancer risk (including skin cancer)
- Nervous system effects (eg, PRES)
Contact your healthcare professional for any adverse effects. Report to FDA at 1‑800‑FDA‑1088 or www.fda.gov/medwatch.
Who should avoid taking Stelara?
Avoid if you have allergy to ustekinumab or any inactive ingredients.
What should you tell your healthcare provider before using Stelara?
Disclose any:
- Latex allergy (syringe cap contains latex)
- Recent or planned live vaccination
- Skin lesions
- Allergy shots (may be less effective)
- Phototherapy history
- Pregnancy or breastfeeding plans
Is Stelara infusion covered by Medicare?
Part B covers many physician-administered biologics. Consult your provider or CMS to confirm coverage for Stelara infusions.
How much does one shot of Stelara cost?
The average retail cost of a 1 mL prefilled syringe (90 mg/mL) is over $49,000. Maintenance dosing varies by condition (every 8–12 weeks).
Cost-saving options:
- Choose a Part D plan that covers Stelara
- Explore patient assistance programs (Stelara withME, Janssen CarePath)
- Check state Medicaid eligibility
- Use coupons or discount cards
- Compare pharmacy prices
- Ask about alternative treatments
Related Medications
- Humira (adalimumab)
- Cosentyx (secukinumab)
- Dupixent (dupilumab)
- Fasenra (benralizumab)
- Nucala (mepolizumab)