By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (ustekinumab) Covered by Aetna (CVS Health) in Washington: Complete Guide to Prior Authorization, Appeals, and External Review

Answer Box: Getting Stelara (ustekinumab) Covered by Aetna (CVS Health) in Washington

Stelara requires prior authorization from Aetna with step therapy requirements (failed conventional treatments like methotrexate or TNF inhibitors), negative TB screening within 12 months, and specialist documentation. Fastest path: Call Aetna at 1-888-632-3862 to confirm your plan's formulary tier and PA requirements, gather required clinical documentation, and submit through your provider's portal. If denied, Washington residents can appeal internally then request external review through the Office of the Insurance Commissioner (OIC) at 1-800-562-6900.

Table of Contents

  1. Coverage Basics: Is Stelara Covered?
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Clinical Criteria and Requirements
  5. Costs and Financial Assistance
  6. Denials and Appeals in Washington
  7. Renewals and Ongoing Coverage
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics: Is Stelara Covered?

Stelara (ustekinumab) is covered by most Aetna (CVS Health) plans in Washington, but it requires prior authorization and is typically classified as a specialty-tier medication. The drug is FDA-approved for moderate-to-severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before filling Aetna Precertification List Aetna 2025 PA List
Formulary Tier Specialty (non-preferred) Plan-specific formulary Call 1-888-632-3862
Step Therapy Must try/fail conventional treatments Aetna Clinical Policy Aetna Policy 0912
Quantity Limits 1 syringe per 56 days (standard) Plan documents Verify with member services
Age Limits 6+ years for most indications FDA labeling Stelara Prescribing Information

Important: Biosimilar versions like Yesintek, Imuldosa, and Pyzchiva may have preferred status over brand Stelara, potentially reducing costs and approval time.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Provider)
    • Call Aetna member services at 1-888-632-3862
    • Confirm formulary status, PA requirements, and copay
    • Expected timeline: 5-10 minutes
  2. Gather Required Documentation (Provider)
    • TB screening results (TST or IGRA within 12 months)
    • Hepatitis B screening
    • Treatment history with dates and outcomes
    • Disease severity documentation
    • Expected timeline: 1-2 weeks
  3. Submit PA Request (Provider)
  4. Track Status (Provider/Patient)
    • Follow up within 5 business days
    • Request expedited review if urgent
    • Expected timeline: 30-45 days standard, 72 hours expedited
Clinician Corner: Medical Necessity Letter Checklist

Your medical necessity letter should include:Patient's diagnosis with ICD-10 codesDisease severity measures (e.g., BSA for psoriasis, CDAI for Crohn's)Prior treatments attempted with specific dates and outcomesContraindications to alternative therapiesClinical rationale for Stelara specificallyDosing plan and monitoring strategyReferences to FDA labeling and clinical guidelines

Timing and Urgency

Standard Timeline

  • Initial PA Decision: 30-45 days from complete submission
  • Expedited Review: 72 hours for urgent cases
  • Level 1 Appeal: 30 days for pre-service, 60 days for post-service
  • Level 2 Appeal: 30 days from Level 1 decision
  • External Review: 30 days (expedited: 72 hours if health jeopardized)

When to Request Expedited Review

  • Active disease flare requiring immediate treatment
  • Risk of permanent disability or organ damage
  • Hospitalization imminent without treatment
  • Provider must document medical urgency

Clinical Criteria and Requirements

All Indications

  • Negative TB screening (TST or IGRA) within 12 months
  • Hepatitis B surface antigen and core antibody testing
  • No active infections or immunocompromised state
  • No concurrent biologic therapy
  • Specialist evaluation (dermatologist for psoriasis, gastroenterologist for IBD)

Condition-Specific Requirements

Psoriasis

  • Moderate-to-severe disease (≥10% BSA or involvement of hands, feet, face, or genitals)
  • Inadequate response to phototherapy (UVB/PUVA) OR
  • Failed/contraindicated conventional systemic therapy (methotrexate ≥3 months, cyclosporine, acitretin)

Crohn's Disease/Ulcerative Colitis

  • Moderate-to-severe active disease documented by endoscopy, imaging, or clinical assessment
  • Inadequate response to conventional therapy
  • For UC: May require prior biologic trial or hospitalization for severe disease

Psoriatic Arthritis

  • Active disease with joint symptoms
  • Inadequate response to conventional DMARDs

Counterforce Health helps patients and providers navigate these complex requirements by analyzing denial letters and crafting targeted appeals that address each payer's specific criteria.

Costs and Financial Assistance

Typical Cost Structure

Stelara is a specialty-tier medication with higher cost-sharing than standard drugs. Exact copays vary by plan but typically involve:

  • 25-50% coinsurance for specialty tiers
  • Or fixed copays ranging from $100-500+ per dose

Financial Assistance Options

  • Janssen CarePath: Manufacturer copay assistance and patient support
  • Washington State Pharmaceutical Assistance: For eligible low-income residents
  • Foundation grants: Various patient assistance foundations
  • Biosimilar alternatives: May have lower copays

Denials and Appeals in Washington

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Step therapy not met Document prior treatment failures Pharmacy records, physician notes
Insufficient disease severity Provide objective measures PASI scores, endoscopy reports, imaging
Missing TB screening Submit recent test results TST/IGRA results within 12 months
"Not medically necessary" Medical necessity letter Peer-reviewed literature, guidelines
Quantity limit exceeded Exception request with justification Dosing rationale, weight-based calculations

Washington State Appeals Process

Level 1: Internal Appeal

  • Deadline: 180 days from denial notice
  • Submit to: Aetna Appeals Department
  • Timeline: 30 days (pre-service), 60 days (post-service)
  • Required: Written appeal with supporting documentation

Level 2: Second Internal Appeal (if available)

  • Deadline: 60 days from Level 1 decision
  • Timeline: 30 days
  • May include peer-to-peer review

External Review through Washington OIC

  • Eligibility: After exhausting internal appeals, denial involves >$500 cost, based on medical necessity
  • Deadline: 60 days from final internal denial
  • Contact: Washington Office of the Insurance Commissioner at 1-800-562-6900
  • Process: OIC assigns certified Independent Review Organization (IRO)
  • Timeline: 30 days standard, 72 hours expedited
  • Outcome: Binding decision on Aetna
From Our Advocates

We've seen many Stelara denials overturned at the external review level when patients included peer-reviewed studies showing efficacy for their specific condition and documented failure of preferred alternatives. The key is presenting a comprehensive case that addresses the insurer's stated concerns while demonstrating medical necessity.

Renewals and Ongoing Coverage

Reauthorization Timeline

  • Initial approval: Typically 6-12 months
  • Renewal deadline: Submit 30-60 days before expiration
  • Required updates: Current disease status, treatment response, ongoing necessity

What Changes May Trigger Review

  • Plan formulary updates
  • New biosimilar approvals
  • Updated clinical guidelines
  • Change in disease status

Specialty Pharmacy Requirements

Most Aetna plans require Stelara to be dispensed through CVS Specialty Pharmacy or an approved network specialty pharmacy. This ensures:

  • Proper storage and handling
  • Patient education and support
  • Coordination with prior authorization
  • Insurance billing optimization

Important: Don't start therapy before PA approval, as you may be responsible for the full cost (potentially $20,000+ per dose).

Troubleshooting Common Issues

Portal Access Problems

  • Contact Aetna provider services at 1-800-624-0756
  • Verify current portal URL and login credentials
  • Use alternative submission methods (fax, phone) if needed

Missing Forms or Documentation

  • Download current forms from Aetna's provider portal
  • Verify you're using the most recent version
  • Contact CVS Caremark for specialty-specific requirements

Communication Delays

  • Follow up within 5 business days of submission
  • Request status updates in writing
  • Escalate to supervisor if no response within 10 days

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Stelara in Washington? A: Standard decisions take 30-45 days, but expedited reviews for urgent cases are completed within 72 hours.

Q: What if Stelara is non-formulary on my plan? A: You can request a formulary exception with medical necessity documentation. Biosimilars may be preferred alternatives.

Q: Can I request an expedited appeal in Washington? A: Yes, if your health could be seriously jeopardized by delays. Both internal appeals and external reviews offer expedited options.

Q: Does step therapy apply if I failed treatments outside Washington? A: Yes, documented treatment failures from other states typically satisfy step therapy requirements if properly documented.

Q: What happens if my appeal is denied? A: You can request external review through the Washington OIC, which provides an independent medical review with a binding decision.

Q: Are there alternatives if Stelara isn't approved? A: Yes, biosimilars (Yesintek, Imuldosa, Pyzchiva) or other IL-12/23 inhibitors (Skyrizi, Tremfya) may be options.

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific denial letter, identifying the exact basis for rejection, and crafting evidence-backed rebuttals that speak directly to your insurer's criteria. Our platform pulls the right clinical citations and weaves them into appeals that meet Aetna's procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for plan-specific requirements. Coverage policies and procedures may change. For personalized assistance with insurance appeals, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

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