By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by Cigna in Michigan: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Stelara (Ustekinumab) Approved by Cigna in Michigan

Cigna requires prior authorization for all Stelara prescriptions. Submit a drug-specific PA form with documented prior therapy failures and disease severity scores. If denied, you have 180 days to appeal internally, then 127 days to file external review with Michigan DIFS. Start early—approval typically takes 5-15 business days, but appeals can take 30-60 days.

First step today: Have your doctor download the current Stelara PA form and gather prior treatment records before your next appointment.

Table of Contents

Verify Your Plan and Find the Right Forms

Before starting any prior authorization process, confirm whether your Cigna plan uses Cigna's own formulary or Express Scripts as the pharmacy benefit manager. Check the back of your insurance card:

Most Cigna commercial plans in Michigan use Cigna's own PA process, while some employer plans route specialty drugs through Express Scripts.

Current Stelara PA Forms (Updated 2024-2025)

Cigna publishes two separate forms for ustekinumab products:

  1. Subcutaneous formulation: "Stelara, Ustekinumab (by Janssen), Yesintek (subcutaneous)" - for psoriasis, psoriatic arthritis, and IBD maintenance
  2. IV formulation: "Stelara IV, Selarsdi IV, Ustekinumab IV" - for Crohn's disease and ulcerative colitis induction

Prior Authorization Forms and Requirements

Coverage Requirements by Condition

Condition Age Requirement Severity Documentation Prior Therapy Required
Plaque Psoriasis ≥6 years PASI ≥10 or candidate for phototherapy/systemic therapy ≥1 conventional systemic therapy failure
Psoriatic Arthritis ≥18 years Active arthritis despite treatment Methotrexate or other DMARD trial
Crohn's Disease ≥18 years Moderate-severe active disease Corticosteroids or immunomodulator trial
Ulcerative Colitis ≥18 years Moderate-severe active disease 5-ASA or immunosuppressant failure

Source: Cigna ustekinumab subcutaneous policy

Step Therapy Requirements

Cigna typically requires documented failure, intolerance, or contraindication to preferred agents before approving Stelara. Common step therapy requirements include:

For Psoriasis/Psoriatic Arthritis:

  • Trial of methotrexate, cyclosporine, or phototherapy
  • For biologic-naive patients: may require trial of preferred TNF inhibitor

For IBD:

  • Conventional therapy (5-ASA, corticosteroids, immunomodulators)
  • For biologic-experienced patients: document specific prior biologic failures

Submission Portals and Methods

Electronic Submission (Preferred)

  • CoverMyMeds: Integrated with most EMR systems
  • SureScripts: Available within Epic, Cerner, and other EHRs
  • Cigna Provider Portal: CignaforHCP.com

Fax Submission

Use the fax number printed on the specific PA form:

  • Subcutaneous Stelara: Fax number listed on current form (verify with source linked above)
  • IV Stelara: Separate fax number for infusion requests
Tip: Include a cover sheet with patient name, date of birth, and "URGENT - PRIOR AUTHORIZATION REQUEST" for faster processing.

Medical Necessity Documentation

Required Clinical Information

Your prescriber must document:

Disease-Specific Requirements:

  • Psoriasis: PASI score ≥10, BSA affected, prior therapy details with dates and outcomes
  • Crohn's Disease: CDAI score, Harvey-Bradshaw Index, prior biologic names/doses/duration
  • Ulcerative Colitis: Mayo score, prior treatment timeline

Universal Requirements:

  • ICD-10 diagnosis codes
  • Prior therapy failures (specific drugs, doses, duration, reason for discontinuation)
  • Contraindications to preferred alternatives
  • Specialist involvement (dermatologist for psoriasis, gastroenterologist for IBD)

Letter of Medical Necessity Template

Include these elements in your physician's letter:

  1. Patient demographics and diagnosis
  2. Disease severity with objective measures
  3. Prior treatment history with specific outcomes
  4. Rationale for Stelara over alternatives
  5. Monitoring plan and treatment goals
  6. References to FDA labeling or clinical guidelines

Appeals Process: Internal and External

Cigna Internal Appeals

Timeline: Submit within 180 days of denial notice

Required Documents:

  • Original denial letter
  • Medical records supporting necessity
  • Updated physician letter addressing denial reasons
  • Laboratory results and imaging (if applicable)

Submission Methods:

  • Online: Cigna provider portal
  • Fax: Number provided in denial letter
  • Mail: Address specified in denial notice

Decision Timeline:

  • Standard: 30 days for pre-service, 60 days for post-service
  • Expedited: 72 hours (requires physician attestation of urgency)

Michigan External Review Process

If Cigna denies your internal appeal, Michigan law provides additional protection through the Department of Insurance and Financial Services (DIFS).

Eligibility: After exhausting Cigna's internal appeals process

Timeline: File within 127 days of final internal denial (Michigan's unique timeframe)

How to File:

  1. Online (preferred): difs.state.mi.us/Complaints/ExternalReview.aspx
  2. Paper/Fax: Download Form FIS 0018, fax to 517-284-8838
  3. Phone assistance: 877-999-6442

Decision Timeline:

  • Standard: 60 days maximum
  • Expedited: 72 hours (requires physician letter stating delay would harm patient)

Important: DIFS external review decisions are binding on Cigna. If overturned, your insurer must provide coverage.

Specialty Pharmacy Setup with Accredo

Cigna designates Accredo as their preferred specialty pharmacy for Stelara. Once your PA is approved:

Enrollment Process

  1. Prescription Transfer: Fax completed prescription to 888-302-1028
  2. Patient Enrollment: Accredo will contact you within 24-48 hours
  3. Insurance Verification: Accredo handles Cigna benefit verification
  4. Shipping Coordination: Home delivery or provider office (specify preference)

Accredo Contact Information

  • Phone: 877-826-7657
  • Hours: Monday-Friday 7am-10pm CT, Saturday 7am-4pm CT
  • Address: Memphis, TN (national distribution)
  • NCPDP ID: 4436920
Note: While Accredo is Cigna's preferred specialty pharmacy, some plans may allow other in-network specialty pharmacies licensed in Michigan.

Support Lines and Contacts

Cigna Member Services

  • General: 1-800-244-6224
  • Specialty Pharmacy: 1-800-88-CIGNA (1-800-882-4462)
  • Appeals: Use provider portal or number on denial letter

Michigan Department of Insurance and Financial Services (DIFS)

  • Consumer Hotline: 877-999-6442
  • External Review Questions: Same number
  • Website: michigan.gov/difs

Peer-to-Peer Review

If initially denied, request a peer-to-peer review where your physician speaks directly with Cigna's medical director. This often resolves denials faster than formal appeals.

Michigan-Specific Consumer Protections

Michigan's Patient's Right to Independent Review Act provides stronger protections than federal minimums:

  • Extended appeal window: 127 days vs. federal 120 days
  • Expedited review: 72 hours for urgent cases
  • Binding decisions: External review overturns are mandatory
  • No cost: DIFS external review is free to consumers

Additional Resources:

Common Denial Reasons and Solutions

Denial Reason Required Fix Documentation Needed
Step therapy not met Document prior therapy failures Specific drugs, doses, dates, outcomes
Not medically necessary Provide severity scores PASI ≥10, CDAI scores, Mayo scores
Insufficient trial duration Show adequate trial periods Minimum 3-6 months per therapy
Missing specialist involvement Get specialist consultation Dermatology/GI consultation notes
Incomplete TB screening Submit infection workup TB skin test, chest X-ray, hepatitis panel

From Our Advocates

We've seen many Stelara denials overturned simply by providing more detailed documentation of prior therapy failures. One common issue: listing "methotrexate failure" without specifying the dose, duration, and specific reason for discontinuation. When physicians include details like "methotrexate 25mg weekly for 16 weeks, discontinued due to persistent PASI 18 and elevated liver enzymes," approvals come much faster.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals with the right clinical evidence and procedural requirements. For complex cases like Stelara appeals, we identify the specific denial basis and provide the exact documentation needed for approval. Visit www.counterforcehealth.org to learn how we can help streamline your prior authorization and appeal process.

FAQ

How long does Cigna prior authorization take for Stelara in Michigan? Standard PA decisions take 5-15 business days. Expedited requests (with physician urgency letter) are decided within 72 hours.

What if Stelara is non-formulary on my plan? Request a formulary exception using Cigna's exception process. Provide medical necessity documentation and prior therapy failures.

Can I get an expedited appeal in Michigan? Yes. Both Cigna internal appeals and Michigan DIFS external review offer expedited processing (72 hours) when delay would harm your health. Requires physician letter.

Does step therapy apply if I failed biologics in another state? Yes. Prior therapy history follows you regardless of where treatment occurred. Document all prior failures with medical records.

What if I can't afford Stelara while appealing? Contact Janssen CarePath for patient assistance programs. Some plans also provide temporary "bridge" supplies during appeals.

How often do Michigan external reviews overturn denials? While specific Michigan statistics aren't published, external reviews nationwide overturn 25-50% of denials when proper medical evidence is provided.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan. Always consult your physician and insurance plan documents for specific coverage details. For questions about Michigan insurance laws, contact DIFS at 877-999-6442.

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