By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (ustekinumab) Covered by Cigna in Virginia: Complete Prior Authorization and Appeals Guide

Quick Answer: To get Stelara (ustekinumab) covered by Cigna in Virginia, you'll need prior authorization showing failure of 2+ conventional therapies and specialist involvement. If denied, you have 180 days for internal appeals, then 120 days for Virginia's free external review through the State Corporation Commission. Start by having your doctor submit the Cigna PA form with documented treatment history and clinical rationale.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Stelara formulations Cigna PA policies
Step Therapy Must try 2+ conventional therapies first Cigna coverage criteria
Specialist Requirement Rheumatologist, dermatologist, or GI specialist PA form requirements
Age Limits 6+ years (varies by indication) FDA labeling
Quantity Limits 0.5 fills per 28 days typical Express Scripts formulary
Appeals Deadline 180 days internal, 120 days external Virginia insurance law

Step-by-Step: Fastest Path to Approval

1. Check Your Cigna Plan Coverage Contact Cigna at the number on your insurance card to confirm Stelara is covered and what tier it's on. Ask specifically about prior authorization requirements and whether it's managed through Express Scripts.

2. Gather Documentation Your doctor will need records showing:

  • Diagnosis with appropriate ICD-10 codes (L40.0 for psoriasis, L40.5x for psoriatic arthritis, K50.x for Crohn's)
  • Failed trials of 2+ conventional therapies
  • Current disease severity scores (PASI, CDAI, etc.)
  • Contraindications to preferred alternatives

3. Submit Prior Authorization Your healthcare provider submits the Cigna Stelara PA form with supporting clinical documentation. This typically takes 5-15 business days for a decision.

4. If Denied, File Internal Appeal You have 180 days from the denial date to file an internal appeal with Cigna. Include additional clinical evidence and specialist letters supporting medical necessity.

5. Consider Virginia External Review After exhausting internal appeals, you have 120 days to file for free external review with Virginia's State Corporation Commission if the denial involves medical necessity.

Understanding Cigna's Stelara Requirements

Cigna's 2024 prior authorization criteria for Stelara vary by formulation and indication. Here's what you need to know:

Subcutaneous Stelara (J3357)

For psoriasis and psoriatic arthritis:

  • Must be prescribed by or in consultation with a dermatologist or rheumatologist
  • Documented failure of or contraindication to at least 2 conventional therapies
  • For psoriasis: Must have tried phototherapy (PUVA or narrow-band UVB) where appropriate
  • Age 6 years or older
  • Initial approval typically for 3-6 months

For Crohn's disease maintenance:

  • Must follow IV induction or be continuing established therapy
  • Prescribed by or in consultation with gastroenterologist
  • Documented moderate to severe disease with inadequate response to conventional therapy

Intravenous Stelara (J3358)

Used for Crohn's disease and ulcerative colitis induction:

  • Single-dose induction followed by subcutaneous maintenance
  • Requires failure of conventional therapy plus anti-TNF agents
  • Must be prescribed by gastroenterologist
  • Weight-based dosing (typically 260-520 mg)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Step therapy not met Document specific therapies tried, dates, outcomes, and reasons for discontinuation. Include pharmacy records or prior authorization approvals.
Lack of specialist involvement Obtain consultation note or referral from appropriate specialist (dermatologist, rheumatologist, or gastroenterologist).
Insufficient severity documentation Provide objective disease severity scores (PASI ≥10 for psoriasis, CDAI >150 for Crohn's), photos, or imaging studies.
Missing TB screening Submit tuberculosis screening results including chest X-ray, tuberculin skin test, or interferon-gamma release assay.
Non-formulary status Request formulary exception with clinical rationale explaining why preferred alternatives are inappropriate.

Appeals Playbook for Cigna in Virginia

Internal Appeals Process

Level 1 Internal Appeal

  • Deadline: 180 days from denial notice
  • How to file: Call Cigna member services or submit written appeal
  • Timeline: 30 days for pre-service, 60 days for post-service decisions
  • What to include: Original PA request, denial letter, additional clinical evidence, specialist letter

Level 2 Internal Appeal

  • Available if Level 1 is denied
  • Same timeline and submission process
  • Consider requesting peer-to-peer review with Cigna medical director

Expedited Appeals

  • Available for urgent medical situations
  • 72-hour decision timeline
  • Requires physician certification of urgency

When Internal Appeals Fail

If Cigna upholds the denial after internal appeals, Virginia residents have additional options through the state's external review process.

Virginia External Review Process

Virginia's State Corporation Commission Bureau of Insurance offers free external review for medical necessity denials. This process has helped many patients overturn wrongful denials.

Eligibility Requirements

  • Must have exhausted Cigna's internal appeals (with exceptions for urgent cases and cancer treatment)
  • Denial must involve medical necessity, not contractual exclusions
  • Must file within 120 days of final internal denial
  • Plan must be Virginia-regulated (most employer and individual plans qualify)

How to File

1. Complete Form 216-A Download the External Review Request Form from Virginia's SCC website.

2. Gather Required Documents

  • Copy of Cigna's final denial letter
  • All internal appeal correspondence
  • Medical records supporting the request
  • Physician letter explaining medical necessity

3. Submit to Virginia SCC Mail completed forms to: State Corporation Commission
Bureau of Insurance – External Review
P.O. Box 1157
Richmond, VA 23218

Timeline and Process

  • Within 5 days: Cigna confirms eligibility
  • Within 1 day: SCC assigns Independent Review Organization (IRO)
  • 5 business days: You can submit additional information to IRO
  • 45 days: Standard review decision (72 hours for expedited)

The IRO's decision is binding on Cigna. If they overturn the denial, Cigna must authorize coverage within 1-3 days.

From our advocates: We've seen cases where patients initially denied Stelara for "insufficient step therapy" succeeded on external review by providing detailed pharmacy records showing specific adverse reactions to required first-line treatments. The key was documenting not just that treatments failed, but why they couldn't be continued safely.

Clinician Corner: Medical Necessity Documentation

Healthcare providers can strengthen Stelara prior authorization requests with comprehensive documentation:

Essential Elements

  • Diagnosis specificity: Use precise ICD-10 codes (L40.0 for plaque psoriasis, L40.52 for psoriatic arthritis mutilans)
  • Disease severity: Include objective measures (PASI scores, joint counts, endoscopy findings)
  • Treatment history: Document specific medications tried, durations, outcomes, and reasons for discontinuation
  • Contraindications: Note any medical reasons why preferred alternatives cannot be used
  • Clinical rationale: Explain why Stelara is the most appropriate choice

Supporting Evidence

Reference current treatment guidelines:

  • FDA prescribing information for approved indications
  • American College of Gastroenterology guidelines for IBD
  • American Academy of Dermatology psoriasis treatment recommendations

Billing Considerations

  • Subcutaneous: HCPCS J3357 (billed per mg)
  • Intravenous: HCPCS J3358 (billed per mg)
  • Ensure accurate unit calculations to avoid claim denials

Counterforce Health helps clinicians navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-based appeals that align with payer-specific criteria. Their platform identifies the specific reasons for denials and provides targeted rebuttals using FDA labeling, peer-reviewed studies, and specialty guidelines.

Costs and Patient Support Options

Manufacturer Support

Janssen offers the STELARA® Support program providing:

  • Copay assistance (may reduce costs to $5 per injection for eligible patients)
  • Benefit verification and prior authorization support
  • Injection training and adherence programs

Foundation Assistance

Several patient assistance foundations provide grants for specialty medications:

  • Patient Access Network Foundation
  • Good Days (formerly Chronic Disease Fund)
  • Patient Advocate Foundation

Virginia-Specific Resources

  • Virginia's Medicaid program covers Stelara with prior authorization
  • State pharmaceutical assistance programs may be available for qualifying residents

FAQ

How long does Cigna prior authorization take for Stelara in Virginia? Standard prior authorization decisions are made within 5-15 business days. Expedited requests for urgent medical situations are decided within 72 hours.

What if Stelara is not on Cigna's formulary? You can request a formulary exception by submitting clinical documentation explaining why preferred alternatives are inappropriate. Counterforce Health specializes in crafting these exception requests with evidence-based arguments.

Can I appeal a Cigna denial if I live in Virginia but work in another state? If your insurance is issued in Virginia, you can use Virginia's external review process. Self-funded employer plans may opt into Virginia's process but aren't required to.

Does step therapy apply if I've already tried similar medications in another state? Yes, documented treatment history from other states counts toward step therapy requirements. Ensure your new provider has complete medical records.

What happens if the Virginia external review upholds Cigna's denial? The external review decision is final and binding. Your remaining options include legal action or seeking coverage through other means like manufacturer assistance programs.

How much does Stelara cost without insurance in Virginia? List prices vary but can exceed $20,000 annually. Patient assistance programs and manufacturer support can significantly reduce out-of-pocket costs for eligible individuals.

Can I request an expedited appeal for Stelara? Yes, if your physician certifies that waiting for standard timelines would seriously jeopardize your health. Expedited appeals are decided within 72 hours.

What documentation do I need for a successful Stelara appeal? Include the original denial letter, medical records showing disease severity, documentation of failed prior therapies, specialist consultation notes, and current treatment guidelines supporting Stelara use for your condition.

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage policies may change, and individual circumstances vary. For current information, consult with your healthcare provider and insurance company directly.

Virginia Resources:

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