By Counterforce Health Team in Stelara (ustekinumab) —

Do You Qualify for Stelara (Ustekinumab) Coverage by UnitedHealthcare in Virginia? Decision Tree & Next Steps

Answer Box: Getting Stelara Covered by UnitedHealthcare in Virginia

Quick Answer: UnitedHealthcare now prefers biosimilars (Steqeyma, Yesintek) over brand Stelara as of September 2024. To qualify for Stelara coverage, you'll need prior authorization showing medical necessity and documented failure/intolerance to preferred alternatives. First step: Have your doctor submit a PA request through the UnitedHealthcare Provider Portal with comprehensive clinical documentation. If denied, Virginia offers external review through the State Corporation Commission within 120 days.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If You're "Likely Eligible"
  4. If You're "Possibly Eligible"
  5. If You're "Not Yet Eligible"
  6. If Denied: Virginia Appeal Options
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. FAQ: Stelara Coverage in Virginia

How to Use This Guide

This decision tree helps you determine your path to Stelara coverage with UnitedHealthcare in Virginia. Important change: As of September 2024, UnitedHealthcare has moved Stelara to non-preferred status, requiring medical exceptions for coverage while promoting biosimilars Steqeyma and Yesintek.

Before you start, gather:

  • Insurance card and policy details
  • Complete diagnosis and treatment history
  • Records of prior therapies (medications tried, outcomes, side effects)
  • Recent lab results and clinical assessments
  • Any previous denial letters
Note: This guide applies to UnitedHealthcare commercial and Medicare Advantage plans in Virginia. Medicaid and other state programs may have different requirements.

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

Stelara is FDA-approved for:

  • Moderate-to-severe plaque psoriasis (adults and pediatric patients 6+ years)
  • Active psoriatic arthritis (adults)
  • Moderately to severely active Crohn's disease (adults)
  • Moderately to severely active ulcerative colitis (adults)

✓ YES → Continue to Step 2 ✗ NO → Discuss alternative treatments with your doctor

Step 2: Document Disease Severity

For Psoriasis: You'll typically need:

  • PASI score ≥10 OR
  • Body Surface Area (BSA) ≥10% OR
  • Significant impact on quality of life with objective measures

For IBD (Crohn's/UC): Documentation should include:

  • Active inflammation on endoscopy or imaging
  • Elevated inflammatory markers (CRP, calprotectin)
  • Clinical activity indices showing moderate-to-severe disease

✓ DOCUMENTED → Continue to Step 3 ? UNCLEAR → Request assessment from your specialist

Step 3: Prior Therapy Requirements

UnitedHealthcare typically requires trial and failure of:

  • Conventional therapies (methotrexate, sulfasalazine, corticosteroids)
  • Preferred biosimilars: Steqeyma or Yesintek (as of 2024)
  • Other preferred biologics per your condition

✓ TRIED AND FAILED → You're Likely Eligible ? SOME TRIED → You're Possibly Eligible
✗ NONE TRIED → You're Not Yet Eligible

If You're "Likely Eligible"

Document Checklist for Prior Authorization

Required Clinical Documentation:

  • Complete medical history with diagnosis codes (ICD-10)
  • Severity assessment scores (PASI, CDAI, Mayo Score)
  • Prior medication trials with specific details:
    • Drug names, doses, duration of treatment
    • Reason for discontinuation (ineffective, intolerance, contraindication)
    • Documentation of adverse events
  • Recent laboratory results (TB screening, hepatitis panel, CBC)
  • Treatment goals and expected outcomes

Submission Process

  1. Provider submits PA request through UnitedHealthcare Provider Portal
  2. Alternative submission: Call OptumRx at 888-397-8129
  3. Timeline: Standard processing within 72 hours; urgent requests within 24 hours
  4. Auto-approval: If no response within timeframe, request is automatically approved
Tip: Include a detailed medical necessity letter addressing why biosimilars (Steqeyma/Yesintek) are not appropriate for your specific case.

If You're "Possibly Eligible"

Additional Steps Needed

Request these assessments:

  • Formal disease severity scoring by your specialist
  • Complete documentation of any previous biologic trials
  • Updated laboratory workup if >6 months old
  • Specialist consultation if managed by primary care

Timeline to Reapply:

  • Allow 2-4 weeks for additional testing and documentation
  • Resubmit PA once all requirements are met

Track These Elements:

  • Response to current conventional therapy
  • Any worsening symptoms or complications
  • Quality of life impact measurements
  • Contraindications to preferred alternatives

If You're "Not Yet Eligible"

Alternative Approaches

Immediate Options:

  1. Biosimilar trial: Start with Steqeyma or Yesintek (UnitedHealthcare's preferred options)
  2. Conventional therapy optimization: Maximize current treatments under specialist guidance
  3. Combination therapy: Add conventional agents to current regimen

Exception Request Strategy:

  • Document medical contraindications to step therapy
  • Provide evidence of rapid disease progression requiring immediate biologic intervention
  • Include specialist recommendation for Stelara specifically

Preparing for Future Application:

  • Maintain detailed treatment response logs
  • Schedule regular specialist follow-ups
  • Document any adverse events or treatment failures

If Denied: Virginia Appeal Options

Level 1: Internal Appeal with UnitedHealthcare

Timeline: 180 days from denial notice How to submit:

  • UnitedHealthcare member portal
  • Mail: Check your denial letter for specific address
  • Fax: Provider-specific fax numbers in denial documentation

Required documents:

  • Copy of denial letter
  • Updated medical records
  • Specialist letter of medical necessity
  • Any new clinical evidence

Level 2: Peer-to-Peer Review

Request within: 5-7 business days of denial (verify with your specific plan) Preparation: Have complete patient chart, appeal letter, and clinical rationale ready Key strategy: Address specific denial reasons with UnitedHealthcare medical policy language

Level 3: Virginia External Review

Administered by: Virginia State Corporation Commission Bureau of Insurance Deadline: 120 days from final internal denial Required forms: Form 216-A (standard) or Form 216-C (expedited)

Submit to:

  • Email: [email protected]
  • Fax: (804) 371-9915
  • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (if delay would jeopardize health)
Virginia Advantage: The state allows expedited external review for cancer treatment denials without exhausting internal appeals—a unique provision showing Virginia's commitment to timely care access.

Coverage Requirements at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all Stelara requests UHC PA Requirements List
Preferred Status Non-preferred; biosimilars preferred UHC Formulary Updates
Step Therapy Required trial of Steqeyma/Yesintek UHC Medical Policy
Diagnosis Codes ICD-10 codes for approved indications FDA labeling
Severity Documentation PASI ≥10, active IBD inflammation Clinical assessment
Lab Requirements TB screening, hepatitis panel UHC prior auth policy

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
"Biosimilar available" Document specific contraindication or intolerance to Steqeyma/Yesintek with clinical evidence
"Insufficient severity" Provide updated PASI scores, endoscopy reports, or inflammatory markers showing active disease
"Step therapy not completed" Submit detailed records of prior conventional therapy trials and outcomes
"Missing lab work" Complete TB screening, hepatitis panel, and baseline safety labs
"Experimental/investigational" Cite FDA approval and established clinical guidelines for your specific indication

FAQ: Stelara Coverage in Virginia

Q: How long does UnitedHealthcare prior authorization take in Virginia? A: Standard requests: 72 hours. Urgent requests: 24 hours. If UnitedHealthcare doesn't respond within these timeframes, the request is automatically approved.

Q: What if Stelara is non-formulary on my plan? A: As of September 2024, Stelara is non-preferred. You'll need to demonstrate medical necessity and inability to use preferred biosimilars (Steqeyma or Yesintek).

Q: Can I request an expedited appeal in Virginia? A: Yes. Virginia offers expedited external review (72 hours) if your physician certifies that delay would seriously jeopardize your health or ability to regain function.

Q: Does step therapy apply if I tried medications outside Virginia? A: Yes, properly documented prior therapy trials from other states count toward step therapy requirements. Ensure you have complete medical records transferred.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by UnitedHealthcare. External appeals in Virginia are reviewed by independent medical experts through the State Corporation Commission—offering a fresh, unbiased evaluation.

Q: Are there cost assistance programs for Stelara? A: Yes. The Janssen CarePath program offers copay assistance and patient support services. Eligibility varies by insurance type.

Counterforce Health: Streamlining Your Appeal Process

Getting Stelara approved shouldn't require navigating complex insurance policies alone. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing your specific denial reasons and crafting point-by-point rebuttals aligned with your plan's own rules.

The platform ingests denial letters, plan policies, and clinical notes to identify whether your denial is based on prior authorization criteria, step therapy requirements, or medical necessity determinations. For Stelara cases, Counterforce Health pulls the right evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—while ensuring all required clinical details are properly documented and formatted for your specific UnitedHealthcare plan requirements.

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. For personalized assistance with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560 or visit their consumer services page.

Sources & Further Reading

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