Does Medicare cover Stelara in North Carolina?

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 NC Medicaid, SSI or a Medicare Savings Program, which North Carolina calls MQB (MQB-Q, MQB-B or MQB-E). Otherwise, apply through Social Security at ssa.gov/extrahelp or 1-800-772-1213 (TTY 1-800-325-0778). See Extra Help in North Carolina and MQB in North Carolina.

Getting Stelara covered in North Carolina

North Carolina is its own Part D region (PDP Region 08), so each standalone Part D plan sold here is offered in all 100 counties. For 2027, CMS lists 11 standalone Part D plans from 6 companies in North Carolina. Every county also has Medicare Advantage plans open to everyone, from 11 in Carteret County to 57 in Guilford County. 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 North Carolina counties.

State Health Plan retirees: the Plan's Base Plan and Enhanced Plan are group Medicare Advantage plans that include group Part D, so your Stelara coverage comes from the Plan's formulary. Don't join a separate Part D or Medicare Advantage plan to get Stelara covered: the State Health Plan says that removes you from its group Medicare Advantage plan and moves you to the 70/30 Plan. Ask the Plan first. See the State Health Plan and Medicare.

If you have full NC Medicaid and Medicare, your Medicare drug coverage, not NC Medicaid, pays for Part D drugs like Stelara, and you get Extra Help automatically. See NC Medicaid and Medicare.

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 North Carolina pharmacies: state law (G.S. 90-85.28) lets a pharmacist fill a brand-name prescription with an FDA-approved interchangeable biological product, such as an interchangeable ustekinumab biosimilar, unless your prescriber marks the prescription "Dispense as Written." When the pharmacist dispenses a biological product, the pharmacy must let your prescriber know which product and manufacturer you got within five business days. Make sure the product you get is the one on your plan's formulary.

Hurricanes and power outages: Stelara has storage-temperature limits on its label, so a long power outage can ruin your supply; keep your plan's pharmacy number with your emergency supplies. CMS says Medicare pays to replace prescription drugs lost, destroyed or damaged in a disaster; call your plan for a replacement fill. North Carolina's emergency-refill law (G.S. 58-3-228) is written for state-regulated health plans and the State Health Plan; in a Medicare drug plan, ask the plan itself. See early refills before a hurricane.

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 North Carolina?

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 08: North Carolina)
• State Health Plan — Retiree presentation (group Medicare Advantage plans, outside Medicare plans and the 70/30 Plan)
• CMS — Replacing Durable Medical Equipment and Prescription Drugs after a Disaster
• North Carolina General Statutes — G.S. 58-3-228, extra prescriptions during a state of emergency or disaster
• North Carolina General Statutes — G.S. 90-85.28, selection of equivalent drugs and interchangeable biological products by pharmacists

Frequently asked questions

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