By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by Cigna in Florida: Complete PA Guide with Appeal Forms

Answer Box: Getting Stelara Covered by Cigna in Florida

Cigna requires prior authorization (PA) for Stelara (ustekinumab) in Florida, with step therapy and specialist requirements. Your fastest path: Have your dermatologist or gastroenterologist complete Cigna's PA form showing failed trials of preferred biologics. Submit via CoverMyMeds or fax to complete the process. If denied, you have 180 days for internal appeals and 4 months for external review through Florida's independent reviewers.

First step today: Download the correct PA form and gather your prior treatment records.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Setup
  5. Cost-Share Basics
  6. Submission Process
  7. Appeals Playbook for Florida
  8. Common Denial Reasons & Fixes
  9. Patient Assistance Programs
  10. FAQ

Plan Types & Coverage Implications

Cigna offers several plan types in Florida, each affecting your Stelara coverage differently:

Commercial Plans: Most Florida residents with employer-sponsored Cigna coverage fall into this category. These plans typically route specialty drugs like Stelara through Express Scripts/Accredo specialty pharmacy.

Individual/Family Plans (ACA Marketplace): Available through Healthcare.gov, these plans follow Florida's 4-Tier formulary with consistent PA requirements across tiers.

Medicare Advantage: Different formulary rules apply, often with more restrictive step therapy requirements for biologics.

Note: All plan types require the same PA process for Stelara, but cost-sharing varies significantly.

Formulary Status & Tier Placement

Stelara appears on most Cigna formularies but with important restrictions:

Coverage Status by Plan

  • Cigna Plus Florida 4-Tier: Tier 4 (highest cost-sharing) with PA + Step Therapy
  • National Preferred Plans: Tier 4 with quantity limits
  • Premier Access Plans: Tier 4-5 depending on formulation

Key Coverage Details

  • Prior Authorization: Required for all formulations
  • Step Therapy: Must try preferred biologics first
  • Quantity Limits: 0.5 per 28 days (45mg), 1 per 28 days (90mg)
  • Specialty Pharmacy: Required through Accredo/Express Scripts

As of January 2026, Stelara subcutaneous 45mg/90mg syringes remain Step 1 preferred with no formulary changes.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Source
PA Required Doctor must get approval before prescribing All Cigna plans PA Form
Step Therapy Try other biologics first Policy criteria Coverage Policy
Specialist Required Dermatologist/gastroenterologist prescription PA form Same as above
TB Screening Tuberculin test or IGRA required Clinical documentation FDA labeling requirements
Quantity Limits Weight-based dosing restrictions Formulary Florida PDL

Approval Criteria by Condition

Psoriasis/Psoriatic Arthritis:

  • Moderate-to-severe plaque psoriasis (PASI ≥10 typically)
  • Prescribed by dermatologist or rheumatologist
  • 3-month trial/failure of ≥1 non-ustekinumab biologic
  • Initial approval: 6 months

Crohn's Disease/Ulcerative Colitis:

  • Moderate-to-severe disease activity
  • Gastroenterologist prescription required
  • Prior systemic therapy trial or contraindication
  • IV induction followed by subcutaneous maintenance

Specialty Pharmacy Setup

Cigna routes Stelara through Accredo specialty pharmacy. Here's how to get started:

Step-by-Step Setup Process

  1. Prescription Submission: Your doctor sends the prescription directly to Accredo
  2. Patient Contact: Accredo calls you within 24-48 hours to schedule delivery
  3. Enrollment: Complete the patient enrollment form with insurance information
  4. Account Setup: Register at MyAccredoPatients.com using your Rx number

Required Information for Enrollment

  • Insurance cards (front and back)
  • Emergency contact information
  • Preferred delivery address and timing
  • Clinical information (weight, allergies, concurrent medications)

Direct Contact: Call Accredo at 800-803-2523 to expedite setup or address issues.

Cost-Share Basics

Your out-of-pocket costs depend on your specific plan design:

Typical Structure:

  • Tier 4 drugs often have 25-40% coinsurance after deductible
  • Some plans offer fixed copays ($150-300 per fill)
  • Specialty deductibles may apply separately from medical deductibles
Important: These are educational examples only. Check your Summary of Benefits and Coverage for exact amounts.

Submission Process

Fastest Path to Approval

  1. Download Forms: Get the Stelara Subcutaneous PA form or IV form depending on your treatment
  2. Gather Documentation: Prior therapy records, TB screening, disease severity scores
  3. Complete Medical Necessity Letter: Include diagnosis (ICD-10), prior failures, clinical rationale
  4. Submit via CoverMyMeds: Fastest option for electronic submission
  5. Alternative Submission: Fax completed forms to specialty pharmacy coordinator
  6. Follow Up: Standard review takes 15-30 days; expedited available for urgent cases

Required Documentation Checklist

  • ✅ Completed PA form with all fields
  • ✅ Medical necessity letter from specialist
  • ✅ Prior therapy documentation (dates, doses, outcomes)
  • ✅ TB screening results (IGRA or skin test + chest X-ray)
  • ✅ Disease activity scores (PASI, CDAI, Mayo score)
  • ✅ Insurance cards and patient demographics

Appeals Playbook for Florida

If Cigna denies your Stelara PA, Florida law provides clear appeal rights:

Internal Appeal Process

Timeline: 180 days from denial notice How to File: Cigna member portal, phone (1-800-Cigna24), or written appeal Decision Timeline: 30 days standard, 72 hours expedited Required Documents: Denial letter, additional clinical evidence, physician letter

External Review (Independent)

When Available: After internal appeal denial Timeline: 4 months from final internal denial Cost: Free to patient How to Request: Through Florida Department of Financial Services Decision: Binding on Cigna

Expedited Reviews: Available when delay could seriously jeopardize your health. Mark all submissions "EXPEDITED" and have your physician certify the urgency.

Florida-Specific Resources

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
Step therapy not met Document prior biologic failures with dates, doses, outcomes Pharmacy records, physician notes
Not medically necessary Submit disease severity scores, treatment guidelines PASI scores, ACG/AAD guidelines
Missing TB screening Complete required testing IGRA/TST results, chest X-ray
Wrong specialist Transfer prescription to appropriate specialist New prescription from dermatologist/GI
Quantity exceeded Justify weight-based dosing per FDA label Patient weight, FDA prescribing information

Peer-to-Peer Review Option

Before formal appeals, request a peer-to-peer review where your doctor speaks directly with Cigna's medical director. Call 1-800-88CIGNA within 180 days of denial.

Patient Assistance Programs

Manufacturer Support

Janssen CarePath: Up to $5,000 annual copay assistance for commercial insurance

  • Eligibility: Not on government insurance, income requirements may apply
  • Application: JanssenCarePath.com

Foundation Grants

Patient Advocate Network: Grants for specialty drug copays HealthWell Foundation: Disease-specific assistance funds Good Days: Chronic disease medication assistance

Tip: Apply for assistance programs before starting treatment, as many don't cover retroactive costs.

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each payer's specific requirements, pulling the right clinical evidence and citations to support medical necessity arguments.

FAQ

How long does Cigna PA take for Stelara in Florida? Standard review takes 15-30 days. Expedited reviews for urgent cases are completed within 72 hours. Submit complete documentation to avoid delays.

What if Stelara is non-formulary on my plan? Request a formulary exception through your doctor. Provide clinical justification for why preferred alternatives aren't suitable for your condition.

Can I get emergency supplies while waiting for approval? Contact Accredo for bridge therapy options. Some plans provide 30-day emergency supplies for continuing therapy while appeals are pending.

Does step therapy apply if I failed biologics in another state? Yes, but you'll need complete documentation from your previous providers. Cigna accepts out-of-state treatment records if properly documented.

What counts as medical necessity for Stelara? Failed response to conventional therapy, contraindications to preferred agents, disease severity meeting clinical guidelines, and appropriate specialist management.

How do I request expedited review? Your physician must certify that delay could seriously harm your health. Mark all submissions "EXPEDITED" and include clinical justification for urgency.

When to Escalate

Contact Florida insurance regulators if:

  • Cigna doesn't follow proper appeal timelines
  • You're denied expedited review for urgent conditions
  • The external review process isn't properly handled

Florida Department of Financial Services

  • Consumer Helpline: 877-693-5236
  • Online complaints: myfloridacfo.com/division/consumers/
  • Insurance Consumer Advocate available for systemic issues

For complex denials requiring detailed medical evidence and policy analysis, platforms like Counterforce Health can help build stronger appeals by identifying specific denial reasons and crafting targeted rebuttals with appropriate clinical citations.

Sources & Further Reading

This guide provides educational information about insurance processes and is not medical advice. Consult your healthcare provider for treatment decisions and your insurance company for specific coverage details. Appeal rights and timelines are based on federal and Florida state requirements as of 2024.

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