Q5137 Inj, wezlana, sub cu, 1 mgInjection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg
Status E: excluded from the PFS by regulation.
29 of 29 payer prior-auth lists that name Q5137 require prior authorization or set conditions: Aetna, Arkansas Blue Cross and Blue Shield, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, Cigna, HealthSpring, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Utah, Neighborhood Health Partnership, Oxford Health Plans, Passport by Molina Healthcare (Kentucky), Surest, UnitedHealthcare.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Arkansas Blue Cross and Blue Shield | Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime) | AR | prior auth required | Non-preferred product | Jul 1, 2024 | Medical Benefit Pharmacy Prior Approval List |
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Request from member's PBM | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth required | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | Request from member's PBM | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Request from member's PBM | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Teamsters group (TYW) | AZ | prior auth required | Sep 1, 2026 | Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) | |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Aetna | Commercial | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Medicare Advantage | All | prior auth required | Aug 25, 2026 | Aetna Medicare Part B drug list (partbname.xml) | |
| Aetna | Medicare Advantage | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Cigna | ACA/IFP | All | prior auth required | Jul 1, 2024 | Master Precertification List (For Health Care Providers) | |
| Cigna | Basic Standard | All | prior auth required | Jul 1, 2024 | Master Precertification List (For Health Care Providers) | |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | Jul 1, 2024 | Master Precertification List (For Health Care Providers) | |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2025 | 2026 Q4 Prior Authorization List | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jul 1, 2024 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 | |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 | |
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth required | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 | |
| Oxford Health Plans | Oxford Health Plans | All | prior auth required | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 | |
| Surest | Surest health plans | All | prior auth required | Oct 1, 2026 | Prior Authorization Requirements for Surest Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Commercial | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Mid-Atlantic Health Plans | All | prior auth under conditions | If prior authorization requirements for the drug aren’t met, UnitedHealthcare will call the health care professional’s office within 3 days. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026 |
Q5137 appears in 22 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Centene, Cigna, Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Therapeutic Drug Monitoring of Anti-Tumor Necrosis Factor Blocking Agents (1091) | not covered | Apr 27, 2026 | payer document |
| Aetna | Ustekinumab (0912) | covered if criteria are met | Jul 1, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Antirheumatic Biologicals (L.5.01.404) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Biosimilar Medications (L.5.01.593) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Mississippi | Biosimilar Medications (S.5.01.593) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Mississippi | Chronic Plaque Psoriasis (L.5.01.412) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Crohns Disease And Ulcerative Colitis (L.5.01.415) | listed, no stance | payer document | |
| Centene | Biologic and Non-biologic DMARDs (CP.CPA.194) | covered if criteria are met | May 1, 2026 | payer document |
| Centene | Biologic and Non-biologic DMARDs | covered if criteria are met | Aug 1, 2026 | payer document |
| Centene | Ustekinumab (Stelara), Ustekinumab-aauz, (CP.PHAR.264) | covered if criteria are met | May 1, 2026 | payer document |
| Cigna | Inflammatory Conditions – Ustekinumab Subcutaneous Products Prior Authorization Policy (IP0687) | covered if criteria are met | Jul 1, 2026 | payer document |
| Premera Blue Cross | (effective January 1, 2027) Pharmacologic Treatment of Psoriasis (5.01.629) Page | 23 of 42 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Pharmacologic Treatment of Psoriatic Arthritis (5.01.645) Page | 16 of 24 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Pharmacotherapy of Arthropathies (5.01.550) Page | 35 of 66 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Pharmacotherapy of Inflammatory Bowel Disorder (5.01.563) Page | 38 of 74 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (2026D0034AU) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (CS2026D0034AV) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (for Ohio Only) (CSOH2026D0034.K) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Provider Administered Drugs – Site of Care (2026D0121W) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | Ustekinumab (2026D0045AB) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Ustekinumab (CS2026D0045AI) | listed, no stance | Sep 1, 2026 | payer document |
| Wellmark Blue Cross Blue Shield | Ustekinumab (05.01.28) | listed, no stance | Apr 1, 2026 | payer document |
Prior authorization required or conditional in IN, MS, NE.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.