Effective October 1, 2016, the drug ustekinumab (Stelara^®) is eligible for coverage under the pharmacy benefit for AmeriHealth commercial members who have prescription drug coverage through FutureScripts^®, our pharmacy benefits manager. Stelara^® will continue to be eligible for coverage under the AmeriHealth 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 AmeriHealth 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 AmeriHealth. 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 Provider Partnership Associate or Network Coordinator.

FutureScripts provides pharmacy benefits management services.