By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by Blue Cross Blue Shield in Pennsylvania: Forms, Appeals, and Success Strategies

Quick Answer: Getting Stelara Covered by Blue Cross Blue Shield in Pennsylvania

Blue Cross Blue Shield Pennsylvania requires prior authorization for Stelara (ustekinumab), but approval is achievable with proper documentation. Submit the Medical Injectable Specialty Drug Prior Authorization Form through your provider, including diagnosis codes, prior treatment failures, and clinical rationale. If denied, Pennsylvania's new external review program has overturned 50% of appeals in 2024, giving you strong recourse. Start by gathering your treatment history and working with your doctor to document medical necessity.

First step today: Contact your prescribing physician to request they submit the PA form with your complete treatment timeline and current symptom severity.

Table of Contents

  1. Understanding Blue Cross Blue Shield Pennsylvania's Requirements
  2. Working With Your Doctor: The Partnership Approach
  3. Pre-Visit Preparation: Building Your Case
  4. Creating Your Evidence Kit
  5. Medical Necessity Letter Structure
  6. Supporting Your Provider Through Peer-to-Peer Review
  7. After Your Visit: Staying Organized
  8. Appeals Process: Pennsylvania's Powerful External Review
  9. Common Denial Reasons and Solutions
  10. Costs and Patient Support Programs
  11. FAQ

Understanding Blue Cross Blue Shield Pennsylvania's Requirements

Blue Cross Blue Shield in Pennsylvania operates through two main plans: Highmark Blue Cross Blue Shield (covering central and western PA) and Independence Blue Cross (serving southeastern PA including Philadelphia). Both require prior authorization for Stelara, but their processes differ slightly.

Coverage at a Glance

Requirement Highmark BCBS Independence Blue Cross Source
Prior Authorization Required Required Highmark PA Forms
Form Name Medical Injectable Specialty Drug PA Form Stelara Prior Authorization Form IBX PA Form
Submission Fax or provider portal Fax to 215-761-9580 Verify with current provider resources
Decision Timeline Standard PA timelines apply 2 business days typical Contact plans directly for current timelines
Step Therapy May require conventional therapy failure Often requires prior biologic trials Check current formulary policies
Note: Always verify current requirements with your specific plan, as policies update regularly throughout the year.

Working With Your Doctor: The Partnership Approach

Getting Stelara approved requires a true partnership between you and your healthcare provider. Your doctor has the clinical expertise and access to submit forms, while you bring the detailed symptom history and treatment timeline that strengthens your case.

Set clear expectations early. When you first discuss Stelara, ask your provider about their experience with insurance approvals and whether they anticipate any challenges with your specific plan. Many dermatologists and gastroenterologists have dedicated staff who handle prior authorizations regularly.

Establish your shared goal: securing approval on the first submission rather than going through denials and appeals. This saves time for both of you and gets you started on treatment faster.

From Our Advocates

We've seen the strongest approvals when patients come prepared with a detailed timeline of what they've tried and how it worked (or didn't). One patient created a simple chart showing six months of methotrexate with persistent joint pain scores, then three months of Humira with initial improvement followed by loss of response. That documentation helped their rheumatologist write a compelling medical necessity letter that got approved immediately.

Pre-Visit Preparation: Building Your Case

Before your appointment, gather comprehensive documentation of your condition and treatment history. This preparation makes your visit more efficient and ensures nothing important gets missed in the prior authorization.

Symptom Timeline and Functional Impact

Create a detailed record of your symptoms over the past 6-12 months:

For Psoriasis/Psoriatic Arthritis:

  • Body surface area affected (percentage)
  • Joint pain and swelling locations
  • Morning stiffness duration
  • Impact on daily activities (work, sleep, relationships)
  • Photos of affected areas (with dates)

For Inflammatory Bowel Disease (Crohn's/Ulcerative Colitis):

  • Bowel movement frequency and consistency
  • Abdominal pain severity (1-10 scale)
  • Weight changes
  • Fatigue levels
  • Emergency room visits or hospitalizations

Prior Treatments Documentation

List every medication you've tried for your condition, including:

  • Medication name and dosage
  • Duration of treatment
  • Reason for discontinuation (lack of efficacy, side effects, contraindications)
  • Specific side effects experienced
  • Lab results showing treatment monitoring

Common prior therapies insurers expect:

  • Psoriasis: Topical corticosteroids, methotrexate, phototherapy
  • Psoriatic Arthritis: Methotrexate, sulfasalazine, other DMARDs
  • IBD: 5-ASA medications, corticosteroids, immunomodulators, other biologics

Creating Your Evidence Kit

Work with your healthcare team to compile supporting documentation that strengthens your prior authorization request.

Essential Medical Records

  • Recent lab results (inflammatory markers like CRP, ESR)
  • Imaging studies (MRI, CT scans, colonoscopy reports for IBD)
  • Pathology reports confirming diagnosis
  • Specialist consultation notes
  • Hospital discharge summaries (if applicable)

Clinical Guidelines and References

Your provider may reference these evidence-based guidelines in your medical necessity letter:

  • Psoriasis: American Academy of Dermatology guidelines for moderate-to-severe disease
  • IBD: American College of Gastroenterology or Crohn's & Colitis Foundation recommendations
  • FDA prescribing information for Stelara showing approved indications

Treatment History Summary

Create a one-page summary showing:

  1. Diagnosis with ICD-10 codes
  2. Chronological list of treatments tried
  3. Current disease activity measures
  4. Functional limitations
  5. Treatment goals with Stelara

Medical Necessity Letter Structure

The medical necessity letter is often the most critical component of your prior authorization. Janssen provides sample templates that your provider can customize for your situation.

Key Components Your Provider Should Include:

1. Patient and Request Details

  • Your name, date of birth, insurance information
  • Specific request: "Authorization for Stelara (ustekinumab) for [condition]"
  • Requested dosing: IV induction followed by subcutaneous maintenance (for IBD) or subcutaneous only (for psoriasis/PsA)

2. Clinical Diagnosis and Severity

  • Primary diagnosis with ICD-10 codes
  • Disease severity indicators
  • Current symptoms and functional limitations
  • Objective measures (lab values, imaging findings)

3. Prior Treatment History

  • Detailed list of previous therapies
  • Specific reasons for failure or discontinuation
  • Duration of each treatment trial
  • Documentation of inadequate response

4. Medical Rationale for Stelara

  • Why Stelara is medically necessary for your specific case
  • Expected benefits based on clinical studies
  • Risks of delaying treatment
  • Why alternative treatments are inappropriate

5. Supporting References

  • FDA prescribing information
  • Relevant clinical guidelines
  • Published studies supporting use in your condition
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to create point-by-point rebuttals aligned with insurers' own rules.

Supporting Your Provider Through Peer-to-Peer Review

If your initial prior authorization is denied, your provider may request a peer-to-peer review—a phone conversation between your doctor and the insurance company's medical director.

How You Can Help:

  • Provide availability windows when you can be reached if the medical director wants to speak with you directly
  • Prepare a concise case summary highlighting the most compelling points
  • Gather additional supporting documentation that wasn't included in the original submission

Key Points for Peer-to-Peer Discussion:

  1. Severity of your condition and impact on quality of life
  2. Specific failures or contraindications to formulary alternatives
  3. Clinical evidence supporting Stelara for your diagnosis
  4. Urgency of treatment initiation

After Your Visit: Staying Organized

What to Save:

  • Copy of the prior authorization submission
  • All supporting documentation sent to insurance
  • Confirmation of submission (fax confirmations, portal screenshots)
  • Contact information for your provider's PA specialist

Follow-Up Communication:

  • Ask your provider's office about their typical timeline for hearing back
  • Establish how they'll notify you of the decision
  • Confirm the process if additional information is requested

Portal Messaging:

If using your provider's patient portal, keep messages concise and specific:

  • "Following up on Stelara PA submitted [date] - any updates?"
  • "Insurance requested additional labs - when can these be submitted?"

Appeals Process: Pennsylvania's Powerful External Review

Pennsylvania launched its Independent External Review program in January 2024, giving patients a powerful tool for overturning denials. The program has a 50% success rate, meaning half of all appealed denials are overturned in favor of patients.

Internal Appeal (First Step)

If your Stelara prior authorization is denied, start with your insurance company's internal appeal process:

  1. Timeline: Submit within the timeframe specified in your denial letter (typically 60-180 days)
  2. Process: Your provider can submit additional documentation addressing the denial reasons
  3. Outcome: You'll receive a Final Adverse Benefit Determination letter if the internal appeal is unsuccessful

Pennsylvania External Review (Second Step)

After exhausting internal appeals, you can request external review through the Pennsylvania Insurance Department:

Eligibility:

  • Commercial insurance plans (excludes self-funded employer plans)
  • Must have completed internal appeal process
  • Request within 4 months of Final Adverse Benefit Determination

Process:

  1. Submit request online at pa.gov/reviewmyclaim
  2. PID confirms eligibility within 5 business days
  3. Independent review organization (IRO) assigned
  4. Submit additional supporting information within 15 business days
  5. Decision within 45 calendar days (72 hours for expedited cases)

Success Rate: 50.1% of external reviews resulted in coverage approval in 2024

Important: This process only applies to fully-insured commercial plans. If you have employer insurance, verify whether your plan is self-funded (which would exclude you from this process).

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Documentation Needed
Step therapy not completed Document failure/contraindications to required first-line treatments Treatment history with specific outcomes, side effects, or contraindications
Lack of medical necessity Strengthen clinical rationale with objective measures Disease severity scores, lab values, functional assessments, quality of life measures
Non-formulary drug Request formulary exception Evidence that formulary alternatives are inappropriate or have failed
Quantity limits exceeded Justify dosing based on clinical factors Weight-based dosing calculations, treatment response data
Missing prior authorization Resubmit with complete documentation All required forms and supporting materials

Strengthening Your Resubmission:

  • Address each specific denial reason point-by-point
  • Include additional clinical evidence or expert opinions
  • Consider obtaining letters from specialists
  • Reference published studies relevant to your case

Costs and Patient Support Programs

Even with insurance coverage, Stelara can be expensive. Several programs can help reduce your out-of-pocket costs:

Janssen CarePath

  • Eligibility: Patients with commercial insurance
  • Benefits: Copay assistance, benefits investigation, prior authorization support
  • Contact: JanssenCarePath.com or 877-CarePath

Patient Assistance Programs

  • Income-based programs for uninsured or underinsured patients
  • Foundation grants may be available for specific conditions
  • Contact Counterforce Health for assistance navigating these options

Specialty Pharmacy Benefits

  • Many Blue Cross Blue Shield plans require specialty medications to be filled through designated pharmacies
  • These pharmacies often provide additional support services and may offer payment plans

FAQ

How long does Blue Cross Blue Shield PA take in Pennsylvania? Standard prior authorizations typically take 3-5 business days, though complex cases may take longer. Expedited requests for urgent medical situations are processed within 72 hours.

What if Stelara is non-formulary on my plan? You can request a formulary exception by demonstrating that preferred alternatives are inappropriate for your specific medical situation. This requires additional documentation but is often successful with proper justification.

Can I request an expedited appeal? Yes, if your condition is urgent or life-threatening. Pennsylvania's external review process includes expedited timelines (72 hours) for urgent cases.

Does step therapy apply if I've failed treatments outside Pennsylvania? Yes, treatment history from other states is typically accepted as long as it's properly documented. Make sure your provider includes all relevant medical records in your submission.

What happens if my employer plan is self-funded? Self-funded plans are exempt from Pennsylvania's external review process, but they must provide their own appeals procedures. Check your plan documents or contact HR for specific appeal rights.

How much does Stelara cost without insurance? Stelara is a specialty biologic with significant costs. The exact price varies, but patient assistance programs and copay cards can substantially reduce out-of-pocket expenses for eligible patients.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create compelling rebuttals that align with insurers' own criteria, significantly improving approval rates for complex medications like Stelara.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and specific plan terms. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department's Office of Consumer Services.

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