By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by Cigna in Pennsylvania: Coding, Appeals, and Step Therapy Guide

Answer Box: Getting Stelara Covered by Cigna in Pennsylvania

Fastest path to approval: Complete Cigna's prior authorization form with proper ICD-10 codes (L40.0 for plaque psoriasis, K50.x for Crohn's), document step therapy failures, and include specialist notes showing medical necessity. If denied, Pennsylvania's new external review program overturns about 50% of appeals. First step today: Call your prescriber to gather clinical documentation and verify your Cigna plan requires PA for Stelara through Express Scripts.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Stelara Conditions
  3. Product Coding: HCPCS, J-Codes, and NDC Numbers
  4. Clean Request Anatomy: Building Your PA
  5. Frequent Pitfalls and How to Avoid Them
  6. Verification Steps with Cigna
  7. Appeals Playbook for Pennsylvania
  8. Quick Pre-Submission Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Understanding whether Stelara (ustekinumab) gets processed under your medical or pharmacy benefit affects everything from prior authorization forms to copays. Here's how Cigna typically handles it:

IV Stelara (J3358) always goes through the medical benefit because it requires infusion at a healthcare facility. Your doctor's office bills Cigna directly using the medical benefit PA process.

Subcutaneous Stelara (J3357) can go either route:

  • Medical benefit: When administered in your doctor's office
  • Pharmacy benefit: When dispensed through Express Scripts/Accredo for home injection
Tip: Call Cigna member services at the number on your card to confirm which benefit applies to your specific plan and administration method.

Most Cigna members get subcutaneous Stelara through the pharmacy benefit via specialty pharmacy, which means working with Express Scripts for prior authorization and Accredo for dispensing.

ICD-10 Mapping for Stelara Conditions

Your diagnosis codes directly impact approval odds. Cigna requires specific ICD-10 codes that match FDA-approved indications for Stelara:

Coverage at a Glance

Condition ICD-10 Code Documentation Requirements Severity Notes
Plaque psoriasis L40.0 Body surface area %, PASI score, failed topicals Must document "moderate" or "severe" for biologic eligibility
Psoriatic arthritis L40.50-L40.59 Joint involvement, imaging, functional impact Code both skin (L40.0) and joint components
Crohn's disease K50.x series Location, complications, prior therapy failures Include extraintestinal manifestations
Ulcerative colitis K51.x series Extent (proctitis to pancolitis), current activity Document Mayo score or similar if available

Documentation words that strengthen your case:

  • "Moderate to severe" (not just "chronic" or "active")
  • "Failed conventional therapy" with specific drug names and dates
  • "Significant functional impairment" with examples
  • "Contraindicated" for step therapy drugs (with clinical reason)

Product Coding: HCPCS, J-Codes, and NDC Numbers

Proper coding prevents claim rejections and speeds approval. Here's what your healthcare team needs to know:

Stelara Billing Codes

Route HCPCS Code NDC Format Billing Units Typical Benefit
IV J3358 11-digit (5-4-2) 1 mg = 1 unit Medical
Subcutaneous J3357 11-digit (5-4-2) 1 mg = 1 unit Medical/Pharmacy

Unit calculation example: A 90mg subcutaneous dose = 90 billing units under J3357.

NDC requirements: Cigna requires the standard 11-digit format (e.g., 57894-0060-01, not the 10-digit version). Your pharmacy or clinic should verify current NDC numbers with their distributor, as packaging occasionally changes.

Modifiers that may apply:

  • JA: IV administration
  • JB: Subcutaneous administration

Clean Request Anatomy: Building Your PA

A complete prior authorization request includes these essential elements, properly documented:

Required Documentation Checklist

1. Completed PA Form

2. Diagnosis Documentation

  • ICD-10 code matching FDA indication
  • Specialist involvement (dermatologist, gastroenterologist, rheumatologist)
  • Disease severity with objective measures

3. Step Therapy Documentation This is where most requests fail. You must show:

  • Prior conventional therapy trials with specific dates
  • Clinical failure or intolerance with documented reasons
  • Contraindications to required step therapy agents

For Crohn's/UC: Prior trials typically include corticosteroids, immunomodulators, or anti-TNF biologics For psoriasis: Prior systemic therapy (methotrexate, cyclosporine) or other biologics

4. Clinical Response Measures

  • Objective markers (C-reactive protein, fecal calprotectin, endoscopy results)
  • Functional improvements (reduced pain, better quality of life)
  • Treatment goals and monitoring plan
From our advocates: We've seen the strongest approvals when providers include a brief narrative explaining why Stelara specifically is medically necessary over formulary alternatives, citing the patient's unique clinical picture and prior treatment history. Generic statements about "trying everything" don't carry the same weight as specific drug names, dates, and documented outcomes.

Frequent Pitfalls and How to Avoid Them

These common mistakes can delay or derail your Stelara approval:

Pitfall #1: Incomplete step therapy documentation

  • Fix: List each prior medication by name, dose, duration, and reason for discontinuation
  • Include dates and prescriber notes showing inadequate response or adverse effects

Pitfall #2: Using unspecified ICD-10 codes

  • Fix: Use L40.0 (not L40.9) for documented plaque psoriasis
  • Include severity descriptors in clinical notes to match coding

Pitfall #3: Missing TB screening documentation

  • Fix: Include tuberculosis screening results (chest X-ray, interferon-gamma release assay)
  • Required for all biologic approvals

Pitfall #4: Wrong benefit pathway

  • Fix: Confirm medical vs. pharmacy benefit before submitting
  • Use appropriate forms and submission methods for each pathway

Pitfall #5: Insufficient clinical rationale for exceptions

  • Fix: When requesting step therapy override, provide specific medical reasons why formulary alternatives won't work for this patient

Verification Steps with Cigna

Before submitting your PA request, verify these details to avoid delays:

Pre-Submission Verification

1. Confirm Coverage

  • Check if Stelara is on your plan's formulary
  • Verify tier placement and any restrictions
  • Available through Cigna formulary lookup

2. Identify Required Forms

  • Commercial plans: Standard Cigna PA form
  • Medicare plans: May have different requirements
  • Call Cigna provider services to confirm current forms

3. Check Submission Methods

  • Online: Cigna provider portal (fastest)
  • Fax: 1-866-873-8279 (verify current number)
  • Phone: 1-800-88CIGNA for urgent requests

4. Verify Processing Times

  • Standard review: 5-15 business days
  • Expedited review: 72 hours (requires clinical urgency)

Appeals Playbook for Pennsylvania

If Cigna denies your Stelara request, Pennsylvania offers strong appeal rights with a new state-supervised external review program that overturns about 50% of denials.

Step-by-Step Appeals Process

Level 1: Internal Appeal (Required First Step)

  1. Timeline: File within 180 days of denial
  2. How: Submit through Cigna member portal or call member services
  3. Documents: Include any new clinical information, peer-reviewed studies supporting Stelara use
  4. Decision: Within 30 days (expedited: 72 hours for urgent cases)

Level 2: Pennsylvania External Review

  1. Eligibility: After completing internal appeal and receiving Final Adverse Benefit Determination
  2. Timeline: File within 4 months of final internal denial
  3. How: Submit online at pa.gov/reviewmyclaim or call 1-877-881-6388
  4. Cost: Free to consumers
  5. Decision: Within 45 days (expedited: 72 hours)
  6. Success rate: Approximately 50-53% of appeals overturned in favor of patients

Required Documents for External Review:

  • Final denial letter from Cigna
  • All medical records supporting Stelara necessity
  • Prescriber statement explaining why alternatives are inappropriate
  • Any relevant clinical guidelines or studies
Note: Pennsylvania's external review applies to commercial insurance, including marketplace plans through Pennie. Self-funded employer plans (ERISA) are excluded and follow federal appeal processes.

Quick Pre-Submission Checklist

Use this checklist before submitting your Stelara PA to maximize approval odds:

Documentation Audit

  • Correct ICD-10 code matching FDA indication
  • Specialist involvement documented
  • Step therapy failures listed with dates and reasons
  • TB screening results included
  • Disease severity objectively documented
  • Treatment goals clearly stated
  • Proper HCPCS/NDC codes for billing pathway
  • Current forms from Cigna website
  • Complete contact information for prescriber and patient

Submission Details

  • Correct submission method (medical vs. pharmacy benefit)
  • All required signatures on forms
  • Legible documentation (no handwritten notes that can't be read)
  • Follow-up plan for checking status

When Standard Appeals Aren't Enough

If you've exhausted Cigna's internal appeals and Pennsylvania's external review without success, additional options include:

State Insurance Department Complaints Contact the Pennsylvania Insurance Department to file a complaint about improper denials or delays.

Federal Appeals for ERISA Plans Self-funded employer plans follow different rules and may require federal court action after exhausting plan appeals.

Counterforce Health Support Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, potentially improving your chances of approval through strategic documentation and clinical evidence presentation.

Costs and Patient Assistance

While working through the approval process, explore these options to manage costs:

Janssen CarePath

  • Copay assistance up to $20,000 annually for eligible commercial insurance patients
  • Patient support services including injection training
  • Available at janssencarepath.com

Foundation Grants

  • Patient Access Network Foundation
  • Good Days Foundation
  • HealthWell Foundation

State Programs Pennsylvania residents may qualify for additional assistance through state pharmaceutical programs for certain conditions.

FAQ: Common Stelara Coverage Questions

Q: How long does Cigna prior authorization take for Stelara in Pennsylvania? A: Standard review takes 5-15 business days. Expedited review (for urgent medical needs) takes up to 72 hours.

Q: What if Stelara isn't on my Cigna formulary? A: Request a formulary exception with clinical justification. Your doctor must explain why formulary alternatives aren't appropriate for your condition.

Q: Can I get an expedited appeal if I'm already taking Stelara? A: Yes, if discontinuing treatment poses a serious health risk. Your doctor must document the urgency in the appeal request.

Q: Does step therapy apply if I've tried biologics in another state? A: Yes, your complete treatment history counts regardless of location. Ensure all prior therapies are documented in your Pennsylvania medical records.

Q: What's the difference between Cigna's medical and pharmacy benefit for Stelara? A: IV Stelara always goes through medical benefit. Subcutaneous can go through either, depending on where it's administered (office vs. home injection).

Sources and Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult your healthcare provider for medical decisions. Coverage policies and appeal procedures may change; verify current requirements with your insurer and state regulators. For personalized assistance with complex appeals, consider consulting with healthcare coverage specialists like those at Counterforce Health, who can help navigate payer-specific requirements and improve documentation strategies.

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