By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by Blue Cross Blue Shield of Michigan: Timeline, Forms, and Appeals Guide

Quick Answer: Getting Stelara Covered by BCBS Michigan

Blue Cross Blue Shield of Michigan requires prior authorization for Stelara (ustekinumab). Key change: Starting April 1, 2025, BCBS Michigan will only cover Yesintek (ustekinumab biosimilar) for most commercial members, not brand-name Stelara. You'll need step therapy (trying preferred alternatives first), TB screening, and documented disease severity. Submit the Medication Authorization Request Form (MARF) via Availity portal or fax to 1-877-325-5979. Standard review takes 5-7 business days. If denied, you have 127 days to file an external review with Michigan DIFS.

First step today: Contact your prescriber to discuss the transition to Yesintek and ensure your prior authorization documentation is complete.

Table of Contents

  1. What Affects Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Outcomes
  6. If Denied: Appeals Process
  7. Renewal Requirements
  8. Timeline Visual Guide
  9. Time-Saving Tips
  10. Common Denial Reasons & Solutions
  11. Cost Assistance Options
  12. FAQ

What Affects Approval Timing

Several factors determine how quickly BCBS Michigan approves your Stelara request:

Benefit Type & Plan

  • Commercial plans: Standard 5-7 business day review
  • Medicaid plans: May have different timelines
  • Medicare Advantage: Excluded from April 2025 biosimilar transition

Documentation Completeness Complete submissions process faster. Missing elements that cause delays:

  • Incomplete TB screening results
  • Insufficient documentation of prior treatment failures
  • Missing ICD-10 diagnosis codes
  • Unclear dosing rationale

Medical Complexity

  • Straightforward cases (clear diagnosis, documented step therapy): 5-7 days
  • Complex cases requiring medical review: 7-14 days
  • Cases requiring peer-to-peer review: Additional 3-5 days
Important: As of April 1, 2025, BCBS Michigan transitioned most commercial members from brand-name Stelara to Yesintek (biosimilar). Existing Stelara authorizations expired March 31, 2025.

Pre-Submission Preparation (0-2 Days)

Essential Documents Checklist

Patient Information

  • Full name, date of birth, member ID
  • Current insurance card (front and back)
  • Contact information

Clinical Documentation

  • ICD-10 diagnosis code (e.g., K50.9 for Crohn's disease)
  • Documentation of disease severity
  • Complete TB screening results (within 12 months)
  • Prior treatment history with outcomes
  • Current lab results if relevant

Provider Information

  • Prescriber name, specialty, NPI number
  • Office contact information
  • DEA number (if applicable)

Gathering Medical Records

Work with your healthcare team to compile:

  1. Prior Treatment Documentation: Records showing you've tried and failed conventional therapies (immunomodulators, TNF inhibitors)
  2. Severity Assessment: Objective measures of disease activity
  3. TB Screening: Negative QuantiFERON, T-SPOT.TB, or PPD skin test
  4. Contraindication Documentation: If you cannot use preferred alternatives

Submission to Initial Review (1-5 Days)

How to Submit

Electronic Submission (Fastest)

Fax Submission

  • Complete the MARF for Stelara
  • Fax to: 1-877-325-5979
  • Include all supporting documentation

What Reviewers Check First

BCBS Michigan's utilization management team reviews:

  1. Plan eligibility and member status
  2. Diagnosis appropriateness for approved indications
  3. Step therapy compliance - documented failure of preferred agents
  4. Safety requirements - TB screening, contraindications
  5. Dosing appropriateness - FDA-labeled dosing limits

Additional Information Requests (1-7 Days)

If BCBS Michigan needs more information, they'll contact your prescriber within 24-48 hours of submission.

Common Requests

  • Additional clinical notes
  • Lab results or imaging
  • Clarification on prior treatment failures
  • Updated TB screening if expired

How to Respond Quickly

  • Respond within 48 hours to avoid delays
  • Submit complete documentation, not partial responses
  • Use the same submission method (portal or fax)
Tip: Proactively include comprehensive documentation with your initial submission to avoid information requests.

Decision Window & Outcomes

Standard Timeline

  • Approval: 5-7 business days for complete submissions
  • Denial: Same timeline with detailed explanation
  • Pending: Additional information requests extend timeline

Reading Your Approval Letter

Approved authorizations include:

  • Specific product covered (Yesintek vs. brand Stelara)
  • Authorized quantity and duration
  • Approved pharmacy (specialty pharmacy required)
  • Authorization expiration date

If Approved for Yesintek Instead of Stelara

BCBS Michigan's transition means most approvals will be for Yesintek biosimilar. This is therapeutically equivalent to brand Stelara with the same:

  • Dosing schedule
  • Administration method
  • Monitoring requirements
  • Side effect profile

If Denied: Appeals Process

Internal Appeal (First Level)

Timeline: Must file within 180 days of denial Process:

  1. Submit appeal letter explaining medical necessity
  2. Include additional supporting documentation
  3. Request peer-to-peer review if appropriate

Expedited Appeals

For urgent medical situations:

  • Timeline: 72-hour decision for life/health-threatening situations
  • Requirements: Physician letter documenting urgency
  • Process: Mark appeal as "expedited" and provide clinical justification

External Review with Michigan DIFS

If internal appeals fail, Michigan's Department of Insurance and Financial Services (DIFS) provides binding external review.

Key Details:

  • Deadline: 127 days from final denial
  • Timeline: 60 days for standard review, 72 hours for expedited
  • Cost: Free to patients
  • Decision: Binding on BCBS Michigan

How to File:

  1. Complete DIFS external review form
  2. Submit online, by mail, fax, or email
  3. Include all medical documentation
  4. Contact DIFS at 877-999-6442 for assistance

Renewal Requirements

When to Renew

  • Yesintek authorizations approved after April 1, 2025 are valid through March 31, 2026
  • Submit renewal requests 30-60 days before expiration
  • Earlier submission recommended for complex cases

Renewal Documentation

Required Elements:

  • Updated clinical assessment
  • Evidence of treatment response
  • Continued medical necessity
  • Current lab monitoring results
  • Documentation of adherence

Streamlined Process: If you're stable on therapy with good response, renewals typically process faster than initial authorizations.

Timeline Visual Guide

Phase Timeline Key Activities Success Tips
Preparation 0-2 days Gather documents, complete forms Use checklist, verify TB screening current
Submission 1 day Submit via portal or fax Submit electronically when possible
Initial Review 5-7 days BCBS reviews for completeness Respond quickly to information requests
Decision 1-2 days Approval/denial notification Read decision letter carefully
Appeal (if needed) 180 days to file Internal appeal process Include new supporting evidence
External Review 127 days to file DIFS independent review Work with prescriber on documentation

Time-Saving Tips

Portal Optimization

  • Create Availity account for electronic submissions
  • Save patient templates for faster future requests
  • Use portal messaging for status updates

Documentation Bundling

Submit comprehensive packages including:

  • Complete medical history
  • All relevant lab results
  • Detailed treatment timeline
  • Clear clinical rationale

Specialty Pharmacy Coordination

  • Establish relationship with approved specialty pharmacy
  • Coordinate timing between authorization and prescription
  • Verify pharmacy has Yesintek in stock

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Step therapy not met Document failure/intolerance of preferred agents Treatment records, side effect documentation
Insufficient TB screening Complete current screening Negative QuantiFERON or PPD within 12 months
Lack of severity documentation Provide objective disease measures Clinical assessments, imaging, lab results
Non-formulary (brand Stelara) Request Yesintek or formulary exception Clinical justification for brand necessity
Quantity limits exceeded Justify dosing based on FDA labeling Weight-based calculations, clinical rationale

Cost Assistance Options

Manufacturer Support

  • Janssen CarePath: Patient assistance for eligible individuals
  • Copay cards: May reduce out-of-pocket costs
  • Patient assistance programs: For uninsured/underinsured patients

Foundation Support

  • Patient Advocate Foundation: Assistance with insurance appeals
  • HealthWell Foundation: Financial assistance for eligible conditions
  • National Organization for Rare Disorders: Support for qualifying diagnoses

State Resources

  • Michigan DIFS: Free external review services
  • Michigan 2-1-1: General assistance program information

Getting biologic medications like Stelara approved requires patience and thorough documentation, but Michigan patients have strong appeal rights and resources. Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies specific denial reasons and drafts point-by-point responses aligned to each plan's own rules, helping patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements more effectively.

FAQ

How long does BCBS Michigan prior authorization take for Stelara? Standard review takes 5-7 business days for complete submissions. Incomplete requests or complex cases may take 7-14 days.

What's the difference between Stelara and Yesintek? Yesintek is a biosimilar to Stelara with the same active ingredient (ustekinumab), dosing, and effectiveness. BCBS Michigan transitioned to covering Yesintek for most commercial members as of April 2025.

Can I get brand Stelara if Yesintek doesn't work? Yes, you can request a formulary exception with documentation of inadequate response or intolerance to Yesintek.

What if my appeal is denied? You can file for external review with Michigan DIFS within 127 days. This provides an independent medical review that's binding on BCBS Michigan.

Do I need to restart step therapy if I move to Michigan? Generally no, if you have documentation of prior treatment failures from another state, BCBS Michigan should accept this history.

How often do I need to renew authorization? Yesintek authorizations are typically valid for one year. Submit renewal requests 30-60 days before expiration.

What if I need urgent treatment? Request an expedited appeal with physician documentation of urgency. BCBS Michigan must respond within 72 hours for life/health-threatening situations.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. Insurance policies and coverage criteria may change. Verify current requirements with BCBS Michigan and consult official plan documents for the most up-to-date information.

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