Effective October 1, 2016, the drug ustekinumab
(Stelara®) is eligible for coverage under the pharmacy benefit
for
Independence commercial members who have prescription drug coverage through
FutureScripts®, our independent
pharmacy benefits manager. Stelara® will continue to be eligible
for coverage under the Independence medical benefit
for commercial members. Medicare Advantage members are not affected by this
change.
Covering Stelara® under both benefits gives our members
greater access to this medication. Since terms, conditions,
and financial responsibilities (including cost-share [e.g., copayment,
coinsurance, deductible]) vary between medical
and pharmacy benefits, members should be encouraged to research which benefit
is more advantageous for them to
utilize when receiving Stelara®.
Members currently receiving
Stelara®
Members who prefer to continue receiving Stelara® under their
medical benefit will experience no change as a result
of this dual-coverage position. Precertification requirements and cost-share,
based on the terms of the member?s
benefit contract, still apply.
Members who want to have Stelara® covered under their
pharmacy benefit will have to get a new prescription from
their health care provider so they can obtain the drug. They will also need to
learn how to self-administer Stelara®.
Members who have a current precertification approval for
Stelara® through Independence will receive a
one-time automatic transfer of authorization to FutureScripts. Subsequent
changes in benefit coverage will require
a new prior authorization request from the health care provider.
Members new to Stelara®
Members who want to receive Stelara® under the medical
benefit are subject to precertification approval by
Independence. Members who want to receive Stelara® under the
pharmacy benefit are subject to prior authorization
from FutureScripts.
Stelara® under the pharmacy
benefit
Members who are interested in receiving Stelara® under their
FutureScripts pharmacy benefit may have questions
about where to purchase the drug and how to store it. In addition to answering
these questions, providers should ask
if members will be self-administering the drug or bringing it to the office for
administration. For members who bring
Stelara® to the office, providers are reminded that they may
only submit claims for the administration of the drug and
any services rendered during the office visit, not the drug itself.
For more information about the dual coverage of Stelara®,
please contact your Network Coordinator.
FutureScripts is an independent company that provides
pharmacy benefits management services.