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UnitedHealthcare has made a new move in the fight to cope with sky-high costs for severe psoriasis, Crohn's disease and other chronic health conditions.
The UnitedHealth Group division is taking Johnson & Johnson's Stelara — one of the most popular, best-known and most expensive "biologic" anti-inflammatory drugs — off the standard formulary for many plans in New York and New Jersey starting Sept. 1, according to a recent prescription benefits update.
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UnitedHealthcare expects the plans to encourage patients to start with one of two "biosimilars" — the Steqeyma and Yesintek versions of "ustekinumab."
Related: How the biosimilar market really works
Patients may need to get prior approval or go through "step therapy" programs to take either Steqeyma or Yesintek, and they may be able to get permission from plans to use Stelara in some cases, according to the benefits update.
Step therapy programs require patients to try more affordable options, such as low-cost generic drugs, before moving up to more expensive options.
Inflammation control basics: Ustekinumab is an injectable form of "monoclonal antibodies," or artificially grown cells, that can help control the human immune system.
The U.S. Food and Drug Administration approved the Stelara version of the drug for sale in the United States in 2009.
Biocon received permission to sell Yesintek — a "biosimilar," or generic version of the drug — early in December, and Celltrion received permission to sell Steyma, another biosimilar version, about three weeks later.
Stelara has been competing mainly with Humira and Humira biosimilar, which tend to cost even more than Stelara and Stelara biosimilars.
The money: For a typical uninsured patient who uses four syringes of Stelara per year to control a condition such as hard-to-treat psoriasis and qualifies for no discounts, the full retail cost of Stelara could be about $148,000 per year, according to SingleCare.com price data.
In 2023, Stelara cost self-insured U.S. employer health plans about $78,000 for every 1,000 enrollees, or $78 for every employer plan enrollee, and it hit employer plans harder than any drugs other than Humira and Ozempic, according to Milliman.
The full retail cost could be about $25,000 per year for Steqeyma and $18,000 per year for Yesintek for an uninsured patient who qualifies for no discounts, according to Drugs.com pricing and dosage data.
In recent years, UnitedHealthcare and competitors such as Cigna's Express Scripts pharmacy benefit manager arm and CVS Health's Caremark PBM arm have made many changes in coverage rules for the most expensive anti-inflammatory drugs in an effort to keep the drugs from wrecking employers' benefits budgets.
Formulary wars: Biocon noted last month the UnitedHealthcare, UnitedHealth's Optum Rx PBM arm unit, Express Scripts, Cigna's own plans and CVS were already adding Yesintek to commercial plan formularies.
But UnitedHealthcare appears to be the first big prescription drug benefits manager to remove Stelara from standard formularies.
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Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
