By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by Blue Cross Blue Shield in Georgia: Complete PA Guide and Appeal Process

Quick Answer: Getting Stelara Covered by BCBS Georgia

Blue Cross Blue Shield of Georgia (Anthem BCBSGA) requires prior authorization for Stelara (ustekinumab) with mandatory tuberculosis screening and often step therapy requirements. Your fastest path to approval: 1) Complete TB screening (skin test or blood test), 2) Document failed trials of required alternatives like TNF inhibitors, and 3) Submit via Anthem's electronic prior authorization portal for quickest processing. If denied, you have 180 days to file an internal appeal and 60 days after that for external review through the Georgia Department of Insurance.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing BCBS formulary or member portal Anthem GA Forms
TB Screening Skin test or blood test within 12 months Clinical notes, lab results FDA Stelara Label
Step Therapy Trial of TNF inhibitors first (psoriasis) Prior therapy documentation BCBS Coverage Criteria
Specialist Requirement Dermatologist (psoriasis) or gastroenterologist (IBD) Provider credentials Plan documents
Appeals Deadline 180 days from denial Denial letter Georgia DOI Guidelines

Step-by-Step: Fastest Path to Approval

1. Verify Your Plan Coverage

  • Log into your Anthem BCBSGA member portal to check formulary status
  • Call member services (number on your ID card) to confirm PA requirements
  • Timeline: 5-10 minutes

2. Complete Required TB Screening

  • Get tuberculosis skin test (TST) or interferon gamma release assay (IGRA like QuantiFERON)
  • Must be completed within 12 months before starting Stelara
  • Who does it: Your prescribing physician or primary care doctor
  • Timeline: Results available in 2-3 days for blood test, 48-72 hours for skin test

3. Document Prior Treatment Failures

  • Gather records showing inadequate response to required alternatives:
    • Psoriasis: TNF inhibitors (Humira, Enbrel, Remicade), methotrexate, cyclosporine
    • Crohn's/UC: Anti-TNF agents, immunomodulators, corticosteroids
  • Include dates, doses, duration, and reason for discontinuation
  • Timeline: 1-2 weeks to collect records

4. Submit Prior Authorization

  • Preferred method: Electronic PA via Anthem provider portal
  • Alternative: Fax to 800-376-0247 (verify current number)
  • Include: PA form, clinical notes, lab results, prior therapy documentation
  • Timeline: 72 hours for urgent requests, up to 15 business days standard

5. Track Your Request

  • Check status via provider portal or call Anthem Provider Services at 1-800-397-1630
  • Anthem must respond within 30 days for standard requests
  • Timeline: Decision typically within 3-5 business days for electronic submissions

Prior Authorization Forms and Submission

Required Forms

  • Primary Form: Anthem Georgia Prior Authorization Form (search "prior authorization" in forms library)
  • Alternative: Use electronic prior authorization (ePA) system for faster processing
  • Supporting Documents: Clinical notes, lab results, imaging, prior therapy records

Electronic prior authorization through Anthem's provider portal reduces processing time from weeks to days. The system guides you through required fields and flags missing information before submission.

Tip: Electronic submissions are processed 3-5x faster than fax submissions and provide real-time status updates.

Fax Submission

If electronic submission isn't available:

  • General PA Fax: 800-376-0247 (verify current number with provider services)
  • Appeals Fax: 877-876-4992
  • Include cover sheet with member ID, provider NPI, and "URGENT" if applicable

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step Therapy Not Met Document failed trials of preferred alternatives Pharmacy records, clinical notes showing inadequate response or intolerance to TNF inhibitors
Insufficient TB Screening Provide complete tuberculosis evaluation TST or IGRA results, chest X-ray, clinical assessment for latent TB
Lack of Specialist Ensure prescriber is board-certified specialist Dermatologist (psoriasis) or gastroenterologist (IBD) credentials
Missing Clinical Justification Submit detailed medical necessity letter SOAP notes, disease severity scores, treatment goals, guideline references
Quantity Limits Exceeded Justify dosing based on FDA labeling Weight-based dosing calculations, clinical response documentation

Appeals Process for BCBS Georgia

Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • How to File: Anthem member portal, written request, or phone
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Required: Denial letter, additional medical evidence, prescriber support letter

External Review (Second Level)

If your internal appeal is denied, Georgia law provides external review through the state Department of Insurance:

  • Deadline: 60 days from internal appeal denial
  • How to File: Georgia DOI Consumer Services or call 1-800-656-2298
  • Cost: Free to consumer
  • Timeline: 30 business days standard, 72 hours for urgent medical situations
  • Decision: Binding on Anthem if approved
Important: Georgia allows concurrent external review with expedited internal appeals for urgent situations—you don't have to wait for Anthem's decision if your condition poses serious health risks.

Clinician Corner: Medical Necessity Documentation

Essential Elements for PA Success

Clinical Justification Checklist:

  • Specific diagnosis with ICD-10 codes
  • Disease severity assessment (BSA for psoriasis, CDAI/Mayo score for IBD)
  • Prior treatment history with dates, doses, and outcomes
  • Contraindications or intolerances to preferred alternatives
  • Expected treatment goals and monitoring plan

Key Clinical Evidence to Include

  • FDA Labeling: Stelara prescribing information supports use in moderate-to-severe plaque psoriasis, psoriatic arthritis, and inflammatory bowel disease
  • Guideline Support: Reference AAD psoriasis guidelines or ACG IBD guidelines as appropriate
  • Safety Profile: Emphasize favorable safety compared to alternatives if relevant to patient's comorbidities

When appeals become complex or require detailed evidence analysis, platforms like Counterforce Health can help clinicians draft targeted, evidence-backed rebuttals aligned with specific payer requirements and clinical guidelines.

Cost Savings and Patient Support

Manufacturer Support Programs

  • Janssen CarePath: Copay assistance and patient support services
  • Eligibility: Most commercial insurance plans (restrictions may apply)
  • Savings: Up to $5,000 per dose in copay assistance

Foundation Assistance

  • Patient Advocate Foundation: Financial assistance for specialty biologics
  • HealthWell Foundation: Grants for inflammatory conditions
  • National Organization for Rare Disorders (NORD): IBD-specific assistance programs

State Resources

  • Georgia Department of Community Health: Medicaid coverage information
  • Georgians for a Healthy Future: Consumer advocacy and appeals assistance

FAQ: BCBS Georgia Stelara Coverage

How long does BCBS Georgia prior authorization take? Standard requests: up to 15 business days. Electronic submissions typically process in 3-5 business days. Urgent requests must be decided within 72 hours.

What if Stelara isn't on my formulary? You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. Include detailed clinical justification and specialist support.

Can I get expedited approval for urgent situations? Yes. If delay would seriously jeopardize your health, request expedited review. Call member services and have your doctor document the urgency.

Does step therapy apply if I failed TNF inhibitors in another state? Yes, documented failures from other states should satisfy step therapy requirements. Ensure complete pharmacy and medical records are submitted.

What happens if both internal and external appeals are denied? You can file a complaint with the Georgia Department of Insurance, consider legal consultation, or explore alternative funding through manufacturer programs or foundations.

How often do external reviews overturn BCBS denials? While success rates vary, external reviews provide independent medical evaluation and can be effective when proper clinical evidence is presented. Georgia's external review process is designed to be impartial and binding.

Organizations like Counterforce Health specialize in analyzing denial patterns and crafting appeals that address specific payer requirements, potentially improving success rates for complex cases.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For the most current forms and procedures, verify directly with Anthem BCBSGA and the Georgia Department of Insurance.

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