Does Medicare cover Stelara in Florida?

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 shows 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.

The Part D out-of-pocket cap doesn't apply to the Part B dose.

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. In October 2025, CMS determined that a biosimilar version had been approved and marketed, and under the law a drug then leaves the program: CMS removes Stelara from the selected list effective January 1, 2027. The negotiated price applies through December 31, 2026, and not after.

Biosimilars

FDA licensed the first interchangeable ustekinumab biosimilar, Wezlana, in October 2023, and several more since; FDA's Purple Book lists them. For 2027, your plan may cover a ustekinumab biosimilar instead of Stelara.

What changes for Stelara in 2027

From January 1, 2027, plans cover Stelara like any drug without a negotiated price, and some may prefer the biosimilar. Your plan's Annual Notice of Change, mailed by September 30, says whether Stelara stays on the formulary and on what terms. If your plan moves or drops it, you can switch plans during Open Enrollment (through December 7, 2026), ask your prescriber about the biosimilar, or request an exception.

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, and some have none.
• 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

Every Part D plan and Medicare Advantage plan with drug coverage offers the Medicare Prescription Payment Plan. Instead of paying the pharmacy, you get a monthly bill from your plan that spreads your costs across the calendar year. Medicare.gov says there's no cost to participate and no interest, 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 full Florida Medicaid, SSI or a Medicare Savings Program (QMB, SLMB or QI-1, which you apply for through ACCESS Florida). Otherwise, apply through Social Security at ssa.gov/extrahelp or 1-800-772-1213 (TTY 1-800-325-0778). See Extra Help in Florida and Medicare Savings Programs in Florida.

Getting Stelara covered in Florida

Florida is its own Part D region (PDP Region 11), so each standalone Part D plan sold here is offered in all 67 counties. For 2027, CMS lists 11 standalone Part D plans from 6 companies in Florida. Medicare Advantage choices depend on your county, from 7 plans in Monroe County to 52 in Hillsborough County, and most include drug coverage. Each plan has its own formulary, so one plan's coverage of Stelara tells you nothing about another's. Your county's numbers are on Florida counties.

• Full Florida Medicaid and Medicare: your prescriptions are paid by your Medicare drug coverage, not by Florida Medicaid, and Extra Help is automatic. Most people with full Medicaid, including those who also have Medicare, get their Medicaid services through a Statewide Medicaid Managed Care (SMMC) plan; that plan doesn't replace your Medicare drug coverage. See Florida Medicaid and Medicare.
• Florida state retirees: if you keep a State Group Insurance health plan as secondary coverage to Medicare, it includes prescription drug coverage that the State says Medicare approves as creditable, so you don't need a separate Part D plan. In one of the State's group Medicare Advantage (MA-PD) plans, your Stelara coverage comes from that plan's formulary. Ask People First before you join any outside Medicare plan. See Florida state retirees and Medicare.
• Snowbirds: a Florida Part D plan's service area is Florida. Ask your plan whether its pharmacy network includes pharmacies where you spend the rest of the year, or whether it offers mail order. A Part D plan must disenroll you if you're away from its service area for more than 12 months in a row. See prescriptions for snowbirds.
• Hurricanes: Florida law (s. 252.358) requires state-licensed insurers and HMOs to allow early refills when your county is under a hurricane warning or a state of emergency. Medicare drug plans follow federal rules: CMS expects them to allow early refills after a federal disaster declaration, and Medicare.gov says to contact your plan to replace drugs lost or damaged in a disaster, or to fill at an out-of-network pharmacy when you can't reach an in-network one. Stelara has storage-temperature limits on its label, so a long power outage can ruin your supply; keep your plan's and pharmacy's phone numbers with your hurricane supplies. See early prescription refills before a hurricane.
• If your Medicare Advantage plan ends in 2027: your plan sends a non-renewal letter, and you have a special enrollment period through February 28, 2027. To keep Stelara covered without a gap, choose new drug coverage by December 31, 2026. See plans ending in 2027.

Substitution at Florida pharmacies: Florida law (s. 465.0252) lets a pharmacist dispense a biosimilar in place of the prescribed biological product only if FDA has found it interchangeable and your prescriber hasn't expressed a preference against substitution in writing, verbally or electronically. The pharmacist must tell you about the substitution. Make sure the product you get is the one on your plan's formulary.

Florida doesn't have a state drug-assistance program for seniors; Extra Help is the main help with Part D costs. See Does Florida have a state drug assistance program for seniors?

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 or strength 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 Florida?

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 — Medicare Advantage and Part D Landscape files, 2027 (PDP Region 11: Florida)
• CMS — Replacing Durable Medical Equipment and Prescription Drugs after a Disaster
• Medicare.gov — Getting drugs in a disaster or emergency
• CMS — Pharmacy access during a federal disaster declaration: questions and answers for Part D plan sponsors
• Florida Statutes — s. 252.358, emergency prescription refills
• Florida Agency for Health Care Administration — Statewide Medicaid Managed Care
• Florida Division of State Group Insurance — Frequently asked questions for retirees (Part D and creditable coverage)
• eCFR — 42 CFR 423.44 (Part D disenrollment after 12 months out of the service area)
• Florida Statutes — s. 465.0252, substitution of interchangeable biosimilar products

Frequently asked questions

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