Which IBD medications are usually covered by your insurer?
Select an insurer, medication, and condition to see typical commercial coverage, prior authorization, and step therapy requirements, all based on publicly available formulary policies.
Brand Stelara is typically excluded from Aetna standard formularies
Aetna's standard commercial formularies generally exclude brand Stelara (ustekinumab) for ulcerative colitis in favor of preferred alternatives, typically preferred ustekinumab product for your benefit route — some SC pharmacy templates prefer biosimilars (e.g., Pyzchiva); under the medical benefit, Pyzchiva and brand Stelara are both lower-cost options. Employer plans can opt out, and infused vs. self-injected forms may follow different rules. A formulary exception or medical-necessity appeal is usually the path to brand coverage.
- Prior authorization
Exception required
Brand coverage generally requires a formulary exception or medical-necessity review.
- Step therapy
Preferred products first
Must use preferred ustekinumab product for your benefit route — some SC pharmacy templates prefer biosimilars (e.g., Pyzchiva); under the medical benefit, Pyzchiva and brand Stelara are both lower-cost options unless an exception is granted.
- Typical placement
Excluded on some SC pharmacy templates
brand Stelara remains a lower-cost product under Aetna's medical-benefit policy; not an insurer-wide exclusion
- Line of business:
- Commercial
- Reauthorization:
- Continuation requires documented response; CPB 0912 does not state a universal 12-month interval
- PA criteria:
- Moderate-to-severe active ulcerative colitis; gastroenterologist involvement; TB screening; no combination with another biologic or JAK inhibitor (CPB 0912). Product preference differs by benefit route: some CVS Caremark SC pharmacy templates exclude brand Stelara in favor of biosimilars, while Aetna's medical-benefit policy treats brand Stelara and Pyzchiva as lower-cost products.
- Exception path:
- Formulary exception / medical-necessity review documenting failure, intolerance, or contraindication to preferred products; plan sponsors can opt out of template exclusions
- Scope:
- Aetna medical-benefit CPB 0912 versus separate CVS Caremark SC pharmacy formularies; benefit route determines which rules apply.
The access landscape for ulcerative colitis
How restrictive each major insurer's standard commercial formulary is, per medication. Select any cell to see the details above.
- Prior auth
- PA + step therapy
- Brand excluded / off formulary
- Varies by local plan
Standard commercial policies; last reviewed Jul 2026. Coverage depends on your exact plan, employer group, state, and whether the drug is infused (medical benefit) or self-injected (pharmacy benefit). Blue Cross Blue Shield coverage is set by independent local Blue companies, and Kaiser Permanente details reflect Kaiser Northwest policy documents. This tool summarizes publicly available policies and is for informational purposes only. Your individual plan may differ from the public documents cited here. It is not medical or insurance advice. Your selections are not saved or sent to a server; they live only in your browser and this page's web address, so you can bookmark or share a result.