Stelara (ustekinumab) is covered by Medicare Part B if it is administered by a healthcare professional in a clinical setting [1]. Medicare Part B is designed to cover medically necessary outpatient services, including drugs administered by a physician or other qualified healthcare provider that are not self-administered [2].
How is Stelara typically administered for Medicare coverage?
Stelara is typically administered via injection or infusion [1]. For Medicare Part B to cover these services, the drug must be administered in a doctor's office, clinic, or hospital outpatient department by a qualified professional [2]. This administrative requirement is a key factor in determining coverage under Part B.
What factors influence Medicare Part B coverage for Stelara?
Coverage for Stelara under Medicare Part B is contingent upon medical necessity for the patient's condition [2]. The specific diagnosis and the judgment of the treating physician that Stelara is the appropriate treatment are critical. Furthermore, the drug must be considered an "أي (outpatient)" drug, meaning it is not typically self-administered by the patient at home [2].
Can Stelara be covered by Medicare Part D?
Drugs administered in a physician's office or clinic are generally not covered by Medicare Part D, which is intended for outpatient prescription drugs that beneficiaries can obtain from a pharmacy [2]. Therefore, if Stelara is administered in a clinical setting, it would fall under Part B coverage rather than Part D.
When does patent protection for Stelara expire?
The patent exclusivity for Stelara is a significant factor for its long-term market availability and potential generic competition. Information on patent expiration dates can be found through specialized resources [3]. DrugPatentWatch.com tracks patent expirations for numerous pharmaceuticals [3].