By Counterforce Health Team in Stelara (ustekinumab) —

Do You Qualify for Stelara (Ustekinumab) Coverage by Humana in Georgia? Complete Decision Tree & Appeals Guide

Quick Answer: Can You Get Stelara (Ustekinumab) Covered by Humana in Georgia?

Most likely yes if you have moderate-to-severe plaque psoriasis, psoriatic arthritis, or Crohn's disease/ulcerative colitis and have tried preferred treatments first. Humana requires prior authorization and typically mandates step therapy (trying preferred biologics before Stelara). First step today: Check your specific Humana formulary using their Prior Authorization Search Tool and gather documentation of prior therapy failures. If denied, Georgia residents have strong external review rights through the Georgia Department of Insurance within 60 days.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist & Submission
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternatives & Exception Requests
  6. If Denied: Georgia Appeal Path
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Clinician Corner: Medical Necessity Letter
  10. FAQ: Humana Stelara Coverage in Georgia

How to Use This Decision Tree

Start by confirming your diagnosis and Humana plan type. Most Humana Medicare Advantage and commercial plans in Georgia require prior authorization for Stelara, with step therapy requirements varying by indication and plan year.

Key point: Humana's 2024-2025 criteria are plan-specific and embedded in electronic tools rather than fixed paper policies. Always verify current requirements using Humana's Prior Authorization Search Tool before starting the approval process.

Eligibility Triage: Do You Qualify?

Step 1: Diagnosis Confirmed?

You need one of these FDA-approved indications:

  • Moderate-to-severe plaque psoriasis (≥6 years old)
  • Active psoriatic arthritis (≥6 years old)
  • Moderately to severely active Crohn's disease (≥18 years old)
  • Moderately to severely active ulcerative colitis (≥18 years old)

Prescriber requirement: Dermatologist (psoriasis/PsA), rheumatologist (PsA), or gastroenterologist (IBD) must prescribe or co-manage.

Step 2: Disease Severity Met?

For psoriasis:

  • Body surface area (BSA) ≥3%, OR
  • <3% BSA but involves high-impact areas (face, scalp, palms, soles, genitals) causing functional impairment

For psoriatic arthritis:

  • Actively inflamed peripheral joints, OR
  • Dactylitis, enthesitis, or axial involvement, OR
  • Active skin/nail psoriasis with joint symptoms

For Crohn's disease/ulcerative colitis:

  • Persistent symptoms (abdominal pain, diarrhea, bleeding)
  • Weight loss, anemia, elevated inflammatory markers
  • Endoscopic evidence of active inflammation

Step 3: Prior Therapy Requirements?

Humana typically requires documented failure, intolerance, or contraindication to:

Psoriasis:

  • High-potency topical steroids + vitamin D analogs
  • Phototherapy OR systemic agent (methotrexate, cyclosporine, acitretin)

Psoriatic arthritis:

  • At least one conventional synthetic DMARD (methotrexate, sulfasalazine, leflunomide)

IBD (Crohn's/UC):

  • Systemic corticosteroids
  • Thiopurines (azathioprine, 6-MP) or methotrexate
  • Some plans require prior TNF inhibitor trial

Step 4: Required Labs Complete?

Tuberculosis screening (within 12 months):

  • Tuberculin skin test (TST) or interferon-gamma release assay (IGRA)
  • Chest X-ray
  • If positive, must treat latent TB before starting Stelara

Additional screening:

  • Hepatitis B and C testing
  • Complete blood count, liver function tests
  • No active serious infections

If "Likely Eligible": Document Checklist & Submission

Required Documentation

Clinical notes must include:

  • Exact diagnosis with ICD-10 codes
  • Objective severity measures (BSA %, joint counts, stool frequency)
  • Complete prior therapy history with dates, doses, duration, outcomes
  • TB screening results (negative TST/IGRA within 12 months)
  • Hepatitis B/C screening results

Submission pathways:

  • Providers: Humana Provider Portal or fax to pharmacy PA department
  • Members: Humana Member Portal or call member services
  • Part B (infusion) vs Part D (self-injection): Verify benefit type as submission process differs

Timeline Expectations

  • Standard PA decision: 72 hours after receiving complete documentation
  • Expedited PA: 24 hours for urgent cases
  • Step therapy exceptions: Processed with standard PA timeline

If "Possibly Eligible": Tests to Request

Missing severity documentation:

  • Request dermatology assessment with BSA calculation (psoriasis)
  • Obtain joint examination with formal counts (PsA)
  • Schedule colonoscopy or imaging to document IBD activity

Incomplete prior therapy documentation:

  • Contact previous providers for treatment records
  • Document specific reasons for therapy failures (lack of efficacy, adverse effects, contraindications)

Timeline to re-apply: 2-4 weeks after obtaining missing documentation

If "Not Yet": Alternatives & Exception Requests

Preferred Alternatives to Try First

Humana's preferred biologics vary by plan but commonly include:

Exception Request Options

Medical exceptions for step therapy:

  • Preferred drug contraindicated due to medical condition
  • History of serious adverse reaction to preferred agent
  • Already stable on Stelara and switching would cause harm

Process: Submit exception request with PA, including detailed medical justification from prescriber.

If Denied: Georgia Appeal Path

Level 1: Internal Appeal (Humana)

Timeline: 65 days from denial notice to file appeal Process: Submit via Humana Member Portal or mail written request Decision timeframe:

  • Part D appeals: 7 calendar days
  • Part C (medical) appeals: 30 days (pre-service) or 60 days (payment)
  • Expedited appeals: 72 hours or less

Level 2: External Review (Georgia DOI)

If Humana upholds the denial, Georgia residents can request independent external review through the Georgia Department of Insurance.

Key advantages:

  • Free for consumers
  • Independent medical review by specialists in your condition
  • Binding decision on Humana if approved
  • 60-day deadline from final internal denial

How to file:

  1. Complete Georgia DOI external review request form
  2. Submit final Humana denial letter
  3. Include all medical records and prescriber's medical necessity letter
  4. Request expedited review if urgent (72-hour decision)

Standard timeline: 30 business days for decision

From our advocates: We've seen strong success rates when patients submit comprehensive medical records showing clear failure of preferred therapies and detailed specialist letters explaining why Stelara is medically necessary. The key is thorough documentation of the medical rationale, not just checking boxes on prior therapy requirements.

Coverage Requirements at a Glance

Requirement Psoriasis Psoriatic Arthritis Crohn's Disease Source
Prior Authorization Yes Yes Yes Humana PA Search
Step Therapy Usually Usually Varies by plan Part B Step Therapy List
Age Requirement ≥6 years ≥6 years ≥18 years FDA Label
Specialist Required Dermatologist Rheumatologist Gastroenterologist Multiple payer policies
TB Screening Required Required Required CMS Quality Measure
Appeal Deadline 65 days 65 days 65 days Humana Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents Needed
"Step therapy not met" Document preferred drug failures/contraindications Treatment records, adverse reaction notes
"Not medically necessary" Strengthen clinical justification Specialist letter, severity scores, photos
"Experimental/investigational" Cite FDA approval and guidelines FDA label, specialty society recommendations
"TB screening incomplete" Complete required testing Negative TST/IGRA within 12 months
"Non-formulary drug" Request formulary exception Medical necessity letter, alternative drug failures

Clinician Corner: Medical Necessity Letter

Essential Elements

Patient information:

  • Diagnosis with ICD-10 codes
  • Disease duration and progression
  • Current severity with objective measures

Prior therapy documentation:

  • Each medication tried (generic and brand names)
  • Dosing, duration, and dates of treatment
  • Specific reason for discontinuation (inefficacy, adverse effects, contraindications)

Medical rationale for Stelara:

  • Why preferred alternatives are inappropriate
  • Expected clinical benefits
  • Dosing plan (IV induction for IBD, then SC maintenance)
  • Monitoring plan

Supporting evidence:

  • Relevant clinical guidelines (American College of Rheumatology, American Gastroenterological Association)
  • FDA-approved indications and dosing
  • Peer-reviewed literature if off-label use

Template Language

"Patient has moderate-to-severe [condition] with [specific severity measures]. Despite adequate trials of [list preferred therapies with dates and outcomes], disease remains active with significant functional impairment. Ustekinumab is FDA-approved for this indication and recommended by [relevant guidelines]. Alternative therapies are contraindicated due to [specific medical reasons] or have failed to provide adequate disease control."

FAQ: Humana Stelara Coverage in Georgia

Q: How long does Humana prior authorization take in Georgia? A: Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests are processed within 24 hours for urgent cases.

Q: What if Stelara is non-formulary on my plan? A: You can request a formulary exception with medical necessity documentation. Your prescriber must explain why covered alternatives would be less effective or cause adverse effects.

Q: Can I request an expedited appeal in Georgia? A: Yes, both Humana internal appeals and Georgia external review offer expedited processes when delay could seriously jeopardize your health.

Q: Does step therapy apply if I failed preferred drugs outside Georgia? A: Yes, documented failures from any provider location count toward step therapy requirements. Ensure you have complete treatment records.

Q: What's the success rate for external review in Georgia? A: While Georgia doesn't publish drug-specific data, national external review programs show meaningful overturn rates (30-60%) when strong medical documentation is provided.

Q: How much does Stelara cost with Humana coverage? A: Costs vary by plan tier and copay structure. Check your specific plan's formulary for tier placement and estimated out-of-pocket costs.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific rules, pulling the right clinical evidence and operational details payers expect to see.

When navigating Humana's prior authorization process in Georgia, having the right documentation and understanding the appeals timeline can make the difference between approval and denial. Counterforce Health's systematic approach to appeals has helped many patients successfully obtain coverage for specialty biologics like Stelara.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual medical circumstances and specific plan benefits. Always consult with your healthcare provider and review your actual insurance policy for coverage details.

For additional help with insurance appeals in Georgia, contact:

Sources & Further Reading

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