By Counterforce Health Team in Stelara (ustekinumab) —

Getting Stelara (Ustekinumab) Covered by Humana in Pennsylvania: Complete 2025 Guide to Prior Authorization and Appeals

Quick Answer: Your Path to Stelara Coverage

Humana Medicare Advantage typically requires prior authorization for Stelara (ustekinumab), with step therapy often required for psoriasis, Crohn's disease, and psoriatic arthritis. IV induction is covered under Part B; maintenance injections under Part D through specialty pharmacy. If denied, Pennsylvania's new external review program has overturned 50% of appeals in 2024.

Start today: Call Humana at the number on your member ID card to verify coverage, then have your specialist submit a prior authorization with documented severity scores and prior therapy failures.

Table of Contents

  1. Coverage at a Glance
  2. Understanding Humana's Policy
  3. Medical Necessity Requirements
  4. Step Therapy and Exceptions
  5. Prior Authorization Process
  6. Appeals Process in Pennsylvania
  7. Common Denial Reasons and Solutions
  8. Costs and Financial Assistance
  9. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for most plans Member portal or ID card Humana PA List
Step Therapy Try preferred drugs first Plan's drug formulary Part B Step Therapy
Specialty Pharmacy CenterWell or network pharmacy Prescription drug guide CenterWell Info
TB Screening Required before first dose Clinical notes CMS Quality Measure
Appeals Deadline 65 days from denial Denial letter Medicare Rights

Understanding Humana's Policy

Plan Types and Coverage

Humana covers Stelara differently depending on your specific plan:

  • Medicare Advantage (Part C): Most common in Pennsylvania, with integrated medical and prescription coverage
  • Part D Prescription Drug Plans: For those with Original Medicare
  • Employer Group Plans: May have different formularies

Key distinction: Stelara IV induction is typically covered under Part B (medical benefit) when administered in a clinic, while maintenance subcutaneous injections are covered under Part D (prescription benefit) through specialty pharmacy.

Where Coverage is Determined

Humana maintains separate drug lists for each plan. Check your specific coverage using:

Note: Coverage can vary significantly between plans, even within the same geographic area.

Medical Necessity Requirements

FDA-Approved Indications

Stelara is FDA-approved for:

  • Moderate-to-severe plaque psoriasis (ages 6+)
  • Psoriatic arthritis (ages 6+)
  • Moderate-to-severe Crohn's disease (ages 6+)
  • Moderate-to-severe ulcerative colitis (ages 18+)

Documentation Standards by Condition

For Psoriasis:

  • Baseline severity: PASI score ≥10 or BSA ≥10% or significant involvement of high-impact areas
  • Specialist requirement: Dermatologist diagnosis and ongoing care
  • Response goals: Target PASI 75 improvement or BSA reduction

For Crohn's Disease:

  • Disease activity: CDAI score indicating moderate-to-severe disease (typically ≥220)
  • Specialist requirement: Gastroenterologist diagnosis and management
  • Objective markers: CRP, fecal calprotectin, endoscopic findings when available

For All Indications:

  • TB screening: Negative QuantiFERON or TST within 6-12 months
  • Safety labs: CBC, liver function tests, hepatitis B/C screening
  • Treatment history: Detailed documentation of prior therapies
Clinician Corner: Include specific numeric scores in your medical necessity letter. Phrases like "severe disease" without objective measures often result in denials.

Step Therapy and Exceptions

Required First-Line Treatments

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

For Psoriasis:

  • Topical therapies (corticosteroids, vitamin D analogs)
  • Phototherapy (when appropriate)
  • At least one preferred biologic (often adalimumab or its biosimilars)

For IBD:

  • Conventional therapies (corticosteroids, immunomodulators)
  • At least one TNF-alpha inhibitor (typically infliximab or adalimumab)

Medical Exception Criteria

You can bypass step therapy if you have:

  • Documented contraindications to required medications
  • Previous severe adverse reactions with specific details
  • Clinical factors making preferred agents inappropriate

How to Document Exceptions

Include in your prior authorization:

  • Specific drug names, doses, and dates of prior treatments
  • Detailed reasons for discontinuation (inefficacy, side effects, contraindications)
  • Clinical rationale for why Stelara is medically necessary

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic)
    • Call Humana member services
    • Check if Stelara is on formulary
    • Confirm PA requirements
    • Timeline: Same day
  2. Gather Documentation (Clinic)
    • Medical records with severity scores
    • Prior therapy history
    • Recent lab results and TB screening
    • Timeline: 1-3 days
  3. Submit PA Request (Prescriber)
    • Use Humana's online portal or fax forms
    • Include medical necessity letter
    • Attach supporting documentation
    • Timeline: Same day submission
  4. Humana Review (Automatic)
    • Standard review: 72 hours
    • Expedited review: 24 hours (if urgent)
    • May request additional information
  5. Approval or Denial (Automatic)
    • Approval: Proceed with treatment
    • Denial: Review reason and consider appeal
    • Timeline: Within review period
  6. Appeal if Denied (Patient/Clinic)
    • Internal appeal: 60 days from denial
    • External review: Available after internal appeal
    • Timeline: Varies by appeal level
  7. Treatment Initiation (Patient)
    • Coordinate with specialty pharmacy
    • Schedule infusion or arrange home delivery
    • Begin monitoring plan

Required Documentation Checklist

  • Completed PA form specific to your Humana plan
  • Medical necessity letter from specialist
  • Diagnosis with ICD-10 code
  • Baseline disease severity scores
  • Prior treatment history with outcomes
  • Recent lab results (within 3-6 months)
  • TB screening results
  • Treatment goals and monitoring plan

Appeals Process in Pennsylvania

Pennsylvania has significantly strengthened patient rights with its new Independent External Review program, which has proven remarkably effective for overturning insurance denials.

Internal Appeals (Required First Step)

Timeline: Must be filed within 60-65 days of denial Process: Submit through Humana's member portal or by mail Decision: Humana has 30 days for standard appeals, 72 hours for expedited

Pennsylvania External Review (After Internal Appeal)

Pennsylvania's new state-run external review program launched in January 2024 and has already shown impressive results for patients.

Key Statistics:

  • 517 appeals filed in 2024
  • 259 denials overturned (50.1% success rate)
  • Independent review organizations make binding decisions

Eligibility:

  • Must have completed internal appeal with Final Adverse Benefit Determination
  • Applies to fully insured commercial plans (not self-funded employer plans)
  • Must file within 4 months of final denial

Process:

  1. Submit Request: Use Pennsylvania Insurance Department's online portal
  2. Eligibility Check: PID confirms with insurer within 5 business days
  3. IRO Assignment: Independent Review Organization assigned within 1 business day
  4. Submit Evidence: 15 business days to provide additional documentation
  5. Decision: Standard review within 45 days, expedited within 72 hours

For Urgent Cases: Expedited external review available when delay could seriously jeopardize health

From Our Advocates: We've seen several Pennsylvania patients successfully overturn Stelara denials through the external review process, particularly when the medical necessity letter clearly documented objective severity measures and prior treatment failures. The key is submitting comprehensive clinical evidence during the 15-day window after IRO assignment.

Getting Help with Appeals

  • Pennsylvania Insurance Department Consumer Services: 1-877-881-6388
  • Pennsylvania Health Law Project: Provides free assistance for complex appeals
  • Counterforce Health: Specializes in turning insurance denials into evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted rebuttals that align with payers' own criteria.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Submit objective severity scores PASI ≥10, CDAI scores, specialist notes
"Step therapy not completed" Document prior failures/contraindications Detailed treatment history with dates/outcomes
"Non-formulary drug" Request formulary exception Medical necessity letter explaining why alternatives won't work
"Experimental/investigational" Cite FDA approval and guidelines FDA labeling, clinical guidelines, peer-reviewed studies
"Quantity limits exceeded" Justify dose/frequency Weight-based dosing calculations, treatment response data

Peer-to-Peer Review Strategy

If your initial PA is denied, request a peer-to-peer review where your specialist speaks directly with Humana's medical director. This often resolves denials when:

  • Clinical complexity isn't clear from documentation
  • Unusual circumstances require explanation
  • Standard criteria don't fit your specific case

Costs and Financial Assistance

Humana Coverage Costs

Part B Coverage (IV induction):

  • Subject to Part B deductible and 20% coinsurance
  • Medicare Advantage plans may have different cost-sharing

Part D Coverage (maintenance injections):

  • Specialty tier copayment (typically $47-$150+ per month)
  • May hit catastrophic coverage threshold

Financial Assistance Options

Manufacturer Support:

  • Janssen CarePath savings program
  • May reduce copayments to as low as $5 per month for eligible patients
  • Income and insurance restrictions apply

Foundation Grants:

  • Patient Advocate Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

State Programs:

  • Pennsylvania PACE/PACENET for seniors
  • Medicaid coverage for eligible individuals

FAQ

How long does Humana prior authorization take in Pennsylvania? Standard PA decisions are made within 72 hours. Expedited reviews (for urgent medical needs) are decided within 24 hours. Complex cases may take longer if additional information is requested.

What if Stelara is not on my Humana formulary? You can request a formulary exception by demonstrating medical necessity and that covered alternatives are inappropriate. This requires a detailed medical necessity letter from your specialist.

Can I get expedited appeals in Pennsylvania? Yes, both Humana's internal process and Pennsylvania's external review offer expedited options when delay could seriously jeopardize your health. Your doctor must document the urgent medical need.

Does step therapy apply if I failed these drugs with a different insurer? Yes, documented failures with other insurers should count toward step therapy requirements. Ensure your medical records clearly show the drugs tried, dates, and reasons for discontinuation.

What's the difference between Part B and Part D coverage for Stelara? IV induction doses are typically covered under Part B (medical benefit) when given in a clinic. Maintenance subcutaneous injections are usually Part D (prescription benefit) through specialty pharmacy.

How do I find out my exact Humana plan requirements? Use Humana's drug list lookup tool with your specific plan information, or call the customer service number on your member ID card. Requirements can vary significantly between plans.

When to Escalate

Contact Pennsylvania regulators if:

  • Humana violates appeal deadlines
  • You suspect bad faith denial practices
  • The appeals process isn't followed properly

Pennsylvania Insurance Department: File complaints through their consumer services portal or call 1-877-881-6388.

This article provides general information and should not replace professional medical or legal advice. Coverage policies and appeal processes can change. Always verify current requirements with your specific plan and consult healthcare providers for medical decisions.

Sources & Further Reading:

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