Does Medicare cover Stelara in Oregon?

What Stelara is used for

Stelara is an interleukin-12 and -23 blocker. Its FDA label covers plaque psoriasis (adults and children 6 and older), psoriatic arthritis, Crohn's disease and ulcerative colitis in adults.

This page explains Medicare coverage only. Questions about whether Stelara is right for you belong with your prescriber.

Which part of Medicare covers Stelara

Stelara is a clear example of how the same drug can fall under two parts of Medicare:

• Part B covers the single intravenous (IV) starting dose for Crohn's disease or ulcerative colitis, given at an infusion center or doctor's office. You generally pay 20% of the Medicare-approved amount after the Part B deductible, unless you have Medigap or a Medicare Advantage plan with different cost sharing.
• Part D covers the maintenance injections under the skin that you give yourself at home, if your plan's formulary includes Stelara.

Is Stelara on Medicare's negotiated-price list?

CMS selected Stelara in the first round of the Medicare Drug Price Negotiation Program, and its negotiated price took effect January 1, 2026. CMS then removed Stelara from the selected list effective January 1, 2027, under the rule that a drug leaves the program once a generic or biosimilar version is approved and marketed. From 2027, the negotiated price no longer applies.

Generics and biosimilars

FDA licensed the first interchangeable ustekinumab biosimilar, Wezlana, in October 2023, and several more since; CMS determined in October 2025 that a biosimilar was approved and marketed. For 2027, your plan may cover a ustekinumab biosimilar instead of Stelara. FDA's Purple Book lists the licensed products.

What changes for Stelara in 2027

The negotiated price applies through December 31, 2026. From January 1, 2027, plans set Stelara's coverage like any other drug, and some may move to a biosimilar. Read your Annual Notice of Change. If your plan stops covering Stelara and your prescriber wants you to stay on it, ask for a formulary exception; if a biosimilar is fine for you, check that it's on the plan's formulary.

What you pay for Stelara in 2027: the out-of-pocket cap

Your cost for Stelara depends on your plan: its deductible, the tier it puts the drug on, and whether you use a preferred pharmacy. This site doesn't list plan costs; your plan's formulary and Evidence of Coverage do. What Medicare sets for everyone with Part D is the limit:

• 2027 out-of-pocket cap: $2,400 (it was $2,100 in 2026). Once what you pay for covered Part D drugs (deductible, copays and coinsurance) reaches the cap, you pay nothing more for covered Part D drugs for the rest of 2027.
• The maximum Part D deductible for 2027 is $700. No plan can set a higher deductible.
• Only covered drugs count. If your plan doesn't cover Stelara and you pay cash, or you use a discount card instead of your plan, that spending doesn't count toward the cap.

Spreading the cost: the Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan lets you pay your Part D drug costs in monthly bills from your plan across the calendar year instead of all at once at the pharmacy. Medicare.gov says there's no cost to participate, but it doesn't lower your drug costs; it only changes when you pay. It helps most when costs are high early in the year. To join, call your plan or use its website. More in What is the Medicare Prescription Payment Plan?

Extra Help with Stelara

Extra Help (the Low-Income Subsidy) is a federal program that lowers Part D premiums, deductibles and copays. For 2027, CMS caps Extra Help copays for covered drugs at $5.80 for a generic and $14.40 for a brand-name drug, and some people with full Medicaid pay less. You get Extra Help automatically if you have OHP (Medicaid), a Medicare Savings Program or SSI; otherwise apply through Social Security at 1-800-772-1213 or ssa.gov/extrahelp. See Extra Help in Oregon.

Getting Stelara covered in Oregon

Oregon and Washington share Part D region 30, so standalone Part D plans are offered region-wide. For 2027, Oregon has 8 standalone Part D plans from 4 companies, plus Medicare Advantage plans with drug coverage in most counties (61 open to everyone statewide). Each plan has its own formulary, so one plan's coverage of Stelara tells you nothing about another's.

Where you live in Oregon changes your choices. CMS data show no Medicare Advantage plan open to everyone in Grant, Harney, Lake, Umatilla or Union counties for 2027 (only employer group plans), and only a special needs plan in Curry County. If you live there, coverage for Stelara usually comes from a standalone Part D plan alongside Original Medicare, unless you have employer or other drug coverage. Check your county's numbers on Oregon counties.

If you have both Medicare and OHP, OHP doesn't pay for drugs that Part D covers. The Oregon Health Authority calls this "OHP with Limited Drug": you need a Part D plan (or a Medicare Advantage plan with drug coverage) for Stelara, and you qualify for Extra Help automatically. See OHP and Medicare.

How to check whether a plan covers Stelara

1. Write down the exact drug. Name, strength and how often you take it. A plan can cover one form of Stelara and not another.
2. Look it up in each plan's formulary. Enter your drugs and ZIP code on PlanMatch or Medicare.gov's Plan Finder to see which plans list Stelara and any rules.
3. Read the rules next to the drug. Prior authorization, step therapy or quantity limits mean your prescriber may need to send the plan information before it pays.
4. Check your 2027 notice. Your plan's Annual Notice of Change says whether Stelara stays on the formulary next year. Open Enrollment runs October 15 to December 7, 2026, for coverage starting January 1, 2027.
5. Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.

If your plan doesn't cover Stelara, you or your prescriber can ask for a coverage determination or a formulary exception. Once the plan has your prescriber's supporting statement, it generally must decide within 72 hours, or 24 hours if your prescriber says waiting could seriously harm your health. New members can usually get a one-time transition supply of a drug they were already taking while they ask for an exception or switch. See How do I appeal a Medicare denial in Oregon?

Sources

• National Library of Medicine — DailyMed: Stelara prescribing information (FDA label)
• Medicare.gov — Drug coverage (Part D)
• Medicare.gov — Prescription drugs (outpatient) under Part B
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
• FDA — Purple Book: licensed biological products, biosimilars and interchangeables
• CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold and Extra Help copays)
• Medicare.gov — Medicare Prescription Payment Plan
• Social Security — Extra Help with Medicare prescription drug plan costs
• CMS — Part D plan files record layout (PDP Region 30: Oregon, Washington)
• Oregon Health Authority — OHP and Medicare

Frequently asked questions

Medicare in your Oregon county

Plans, local agents and help, county by county: Multnomah · Washington · Clackamas · Lane · Marion · Jackson · Deschutes · Linn · Douglas · Yamhill · Benton · Polk · Josephine · Umatilla · Klamath · Coos · Columbia · Lincoln · Clatsop · Malheur · All 36 counties →