How to Get Stelara (Ustekinumab) Covered by Cigna in Texas: Appeals Guide with Forms and Timelines
Quick Answer: Getting Stelara Covered by Cigna in Texas
Step 1: Your doctor submits prior authorization to Cigna (required for all Stelara prescriptions). Step 2: If denied, request a peer-to-peer review within 180 days. Step 3: File internal appeal with medical necessity letter and supporting documents. Step 4: If still denied, request external review through Texas Independent Review Organization within 4 months. Expedited reviews available for urgent cases (72-hour decisions). Start by gathering your denial letter, insurance card, and clinical records today.
Table of Contents
- Understanding Your Stelara Denial
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Common Denial Reasons & How to Fix Them
- Appeals Process for Cigna in Texas
- Medical Necessity Letter Template
- Costs & Patient Assistance
- When to Escalate to State Regulators
- Frequently Asked Questions
Understanding Your Stelara Denial
When Cigna denies Stelara (ustekinumab), they're required to send you a detailed explanation. Look for these key elements in your denial letter:
- Denial reason code (step therapy, non-formulary, quantity limits, medical necessity)
- Appeal deadline (typically 180 days from denial date)
- Required documentation for appeals
- Peer-to-peer review option (if available)
Cigna manages specialty drugs like Stelara through Express Scripts, so your denial may come from either entity. Both follow the same appeal timelines under Texas law.
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Doctor must get approval before prescribing | Cigna Provider Portal | Cigna PA Policy |
| Step Therapy | Must try preferred drugs first | Denial letter or formulary | Cigna Formulary |
| Specialist Requirement | Must be prescribed by or with gastroenterologist (IBD) | PA criteria | Coverage Policy |
| TB Screening | Required before first dose | Medical records | FDA Label Requirements |
| Internal Appeal Deadline | 180 days from denial | Denial letter | Texas Insurance Code |
| External Review Deadline | 4 months from final denial | Final denial letter | Texas DOI Guidelines |
Step-by-Step: Fastest Path to Approval
1. Gather Required Documents
Who: You and your doctor
What: Insurance card, denial letter, medical records, prior therapy documentation
Timeline: Before starting appeal process
2. Request Peer-to-Peer Review
Who: Your doctor
What: Call Cigna at 1-800-88CIGNA to schedule clinical discussion
Timeline: Within 180 days of denial
Expected response: 5 business days
3. Submit Medical Necessity Letter
Who: Your doctor
What: Detailed clinical justification with supporting evidence
How: Cigna Provider Portal or fax to 1-866-873-8279
Timeline: 30 days for standard review, 72 hours for expedited
4. File Internal Appeal if Denied
Who: You or your doctor
What: Formal appeal with additional documentation
Timeline: Must file within 180 days of original denial
5. Request External Review (if needed)
Who: You
What: Independent Review Organization evaluation
Timeline: Within 4 months of final internal denial
Expected response: 72 hours expedited, 20 days standard
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| Step therapy not met | Document failure/intolerance of preferred agents | Treatment history, adverse event records |
| Insufficient severity | Provide PASI score ≥10 (psoriasis) or disease activity measures | Clinical assessments, lab results |
| Missing TB screening | Submit tuberculin skin test or IGRA results | Lab reports, chest X-ray |
| Non-formulary status | Request formulary exception with clinical justification | Medical necessity letter, guideline citations |
| Quantity limits exceeded | Justify dosing based on weight/severity | Prescriber rationale, FDA labeling |
Tip: Counterforce Health helps patients and clinicians turn insurance denials into targeted appeals by analyzing the denial basis and drafting evidence-backed rebuttals aligned to each plan's specific requirements.
Appeals Process for Cigna in Texas
Internal Appeals
- First Level: Submit within 180 days of denial
- Decision timeline: 30 days standard, 72 hours expedited
- Required: Medical necessity letter, supporting documentation
- How to file: Cigna member portal, phone (1-800-88CIGNA), or mail
External Review (Independent Review Organization)
- When available: After internal appeal denial for medical necessity disputes
- Timeline to request: 4 months from final internal denial
- Decision timeline: 72 hours expedited, 20 days standard
- Cost: Paid by Cigna
- Binding: Yes, Cigna must comply if overturned
Expedited Reviews
Available when delay could seriously harm your health. Mark all communications as "EXPEDITED" and explain the urgency.
Clinician Corner: Medical Necessity Letter Checklist
Essential Components
- Patient identification: Name, DOB, member ID, diagnosis with ICD-10 code
- Treatment history: Prior therapies tried, duration, response, reasons for discontinuation
- Clinical rationale: Why Stelara is medically necessary, why alternatives won't work
- Supporting evidence: Lab results, imaging, disease severity scores (PASI, CDAI, Mayo Score)
- Guideline citations: Reference FDA labeling, ACG/AGA guidelines for IBD, AAD guidelines for psoriasis
Key Documentation Requirements
- TB screening: Tuberculin skin test or IGRA results
- Hepatitis screening: For all indications
- Prior biologic failure: Specific agents, doses, duration, adverse effects
- Severity measures: PASI ≥10 for psoriasis, validated IBD activity scores
- Specialist consultation: Required for IBD indications
Organizations like Counterforce Health specialize in analyzing payer policies and crafting medical necessity letters that directly address each plan's specific approval criteria, potentially improving success rates.
From our advocates: We've seen cases where initial denials were overturned simply by including the specific TB screening results and PASI scores that Cigna's policy requires. The key is addressing every criterion in their published guidelines, not just making a general medical necessity argument.
Costs & Patient Assistance
Manufacturer Support
- Janssen CarePath: Copay assistance and patient support services
- Eligibility: Commercial insurance required, income restrictions may apply
- Savings: Up to $5,000 per year in copay assistance
Foundation Grants
- Patient Access Network Foundation: Grants for IBD and psoriasis patients
- HealthWell Foundation: Financial assistance for specialty medications
- Requirements: Income verification, medical documentation
State Programs
Texas residents may qualify for additional assistance through local health departments or community health centers, particularly for uninsured patients.
When to Escalate to State Regulators
Contact the Texas Department of Insurance if:
- Cigna violates appeal timelines
- Required forms or information aren't provided
- You suspect bad faith denial practices
Texas Department of Insurance
Phone: 1-800-252-3439
Website: tdi.texas.gov
Office of Public Insurance Counsel (OPIC)
Phone: 1-877-611-6742
Assists with complex appeals and regulatory complaints
Frequently Asked Questions
How long does Cigna prior authorization take for Stelara in Texas?
Standard reviews take up to 30 days. Expedited reviews for urgent cases are decided within 72 hours.
What if Stelara is non-formulary on my Cigna plan?
Request a formulary exception with a medical necessity letter explaining why formulary alternatives aren't suitable.
Can I request an expedited appeal in Texas?
Yes, if waiting for standard review could seriously harm your health. Mark all submissions as "EXPEDITED."
Does step therapy apply if I tried biologics outside Texas?
Yes, document all prior therapies regardless of where treatment occurred. Cigna accepts out-of-state medical records.
What happens if my external review is denied?
The IRO decision is binding. Consider alternative therapies, manufacturer assistance programs, or consultation with a patient advocate.
How much does Stelara cost without insurance?
List price varies by indication and dosing, typically $10,000-$25,000+ annually. Patient assistance programs can significantly reduce costs.
Can my doctor appeal on my behalf?
Yes, physicians can submit appeals and participate in peer-to-peer reviews. Patient consent may be required for some communications.
What documents should I keep during the appeal process?
Maintain copies of all denial letters, appeal submissions, medical records, and correspondence. Track all deadlines and submission dates.
Sources & Further Reading
- Cigna Prior Authorization Requirements
- Cigna Stelara Coverage Policy (PDF)
- Texas Department of Insurance Appeals Guide
- Stelara Prescribing Information (FDA)
- Janssen CarePath Patient Support
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Appeal processes and timelines may vary based on your specific plan type and circumstances.
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