By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (ustekinumab) Covered by Humana in Ohio: Complete 2025 Guide to Prior Authorization and Appeals

Answer Box: Your Path to Stelara Coverage

Stelara (ustekinumab) is covered by Humana in Ohio at Tier 5 (specialty) with prior authorization required. Most approvals need step therapy completion—trying preferred biologics first—plus TB screening and severity documentation. If denied, you have 65 days to appeal internally, then request external review through Ohio Department of Insurance within 180 days.

First steps today:

  1. Verify your Humana plan covers Stelara at Humana's drug list tool
  2. Schedule TB screening (QuantiFERON or TST) if not done recently
  3. Gather prior therapy failure documentation for your prescriber

Table of Contents

Coverage at a Glance

Requirement Details Where to Verify Source
Prior Authorization Required for all indications Humana PA Lists Humana Provider Portal
Formulary Tier Tier 5 (Specialty) - $47-$150+ copay Drug List Tool Humana Member Portal
Step Therapy Must try preferred biologics first Part B Step Therapy List Humana Policy PDF
TB Screening Required within 6-12 months Provider clinical judgment CDC/IDSA Guidelines
Site of Care IV induction: clinic; maintenance: specialty pharmacy Member ID card or portal Plan documents
Appeals Deadline 65 days from denial (Medicare) Denial letter CMS regulations

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who: You (patient) or clinic staff
Action: Log into Humana's member portal with your member ID to confirm Stelara is on your plan's formulary
Timeline: Same day
Document needed: Member ID card

2. Complete TB Screening

Who: Your prescriber orders; you complete
Action: Get QuantiFERON-TB Gold (preferred) or tuberculin skin test, plus chest X-ray
Timeline: 1-3 days for results
Why required: CDC guidelines mandate screening before immunosuppressive biologics

3. Document Disease Severity

Who: Your specialist
Action: Record objective measures—PASI score ≥10 for psoriasis, CDAI >220 for Crohn's disease
Timeline: During routine visit
Forms: Include in medical necessity letter

4. Prove Step Therapy Completion

Who: Your prescriber's office
Action: Document failed trials of preferred biologics (drug names, doses, dates, reasons for discontinuation)
Timeline: Compile from medical records
Exception: If contraindications exist to preferred agents

5. Submit Prior Authorization

Who: Prescriber via Humana provider portal
Timeline: Standard decision in 72 hours; expedited in 24 hours if urgent
Required docs: PA form, medical necessity letter, labs, prior therapy records

6. Track Decision

Who: You and your clinic
Action: Check portal or call member services number on your ID card
Timeline: Humana must notify within 72 hours
Next step: If approved, coordinate specialty pharmacy; if denied, proceed to appeals

7. Appeal if Denied

Who: You or authorized representative
Action: File internal appeal within 65 days of denial notice
Forms: Coverage determination request form
Timeline: 7 days for Part D, 30 days for Part C decisions

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents to Submit
Insufficient step therapy Document specific failures with dates, doses, adverse events Prior therapy timeline with prescriber notes
Lack of severity documentation Add objective scores (PASI, CDAI, DLQI) Updated medical necessity letter with numeric measures
Missing TB screening Complete and submit results QuantiFERON or TST results plus chest X-ray report
"Not medically necessary" Cite FDA labeling and specialty guidelines FDA prescribing information, peer-reviewed studies
Quantity limits exceeded Justify dosing based on weight/response Clinical rationale for higher dose with references

Appeals Playbook for Ohio

Internal Appeals (First Level)

  • Deadline: 65 days from denial notice for Medicare plans
  • How to file: Online via member portal, mail, or fax (check denial letter for specifics)
  • Timeline: 7 days for Part D drugs, 30 days for Part C pre-service decisions
  • Forms: Humana appeals forms
  • Tip: Request peer-to-peer review with Humana medical director—call the provider number on your member ID card

External Review (Ohio Department of Insurance)

  • Eligibility: After exhausting Humana's internal appeals
  • Deadline: 180 days from Humana's final adverse determination
  • Process: Submit written request to Humana (they forward to Ohio DOI)
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Cost: Free to you
  • Contact: Ohio Department of Insurance at 800-686-1526
From our advocates: "We've seen Ohio external reviews overturn about 50% of specialty drug denials when patients submit new clinical evidence—like recent lab values showing disease progression or peer-reviewed studies supporting off-label use. The key is adding information that wasn't in the original PA request."

Clinician Corner: Medical Necessity Documentation

Essential Elements for Stelara PA Letter

  1. Diagnosis with ICD-10 codes
    • Psoriasis: L40.0 (plaque), L40.50 (arthropathic)
    • Crohn's disease: K50.90
    • Ulcerative colitis: K51.90
  2. Objective severity measures
    • Psoriasis: PASI score ≥12, BSA >10%, DLQI >10
    • IBD: CDAI >220 (Crohn's), Mayo score ≥6 (UC)
  3. Prior therapy failures
    • List specific agents, doses, duration, reason for discontinuation
    • Include dates and prescriber notes on adverse events or lack of efficacy
  4. TB screening results
    • QuantiFERON-TB Gold or TST with reading date
    • Chest X-ray interpretation (within 6-12 months)
    • Risk factor assessment per IDSA guidelines
  5. Treatment plan
    • Dosing schedule based on indication and patient weight
    • Monitoring parameters (CBC, liver function, infections)
    • Expected outcomes and timeline for assessment

Key Supporting References

  • FDA prescribing information
  • American Academy of Dermatology psoriasis guidelines
  • American Gastroenterological Association IBD treatment recommendations

Costs & Patient Assistance

Humana Coverage

  • Tier 5 copay: $47-$150+ per fill (varies by plan)
  • Deductible: May apply before copay kicks in
  • Catastrophic coverage: After $8,000+ out-of-pocket, copay drops significantly

Manufacturer Support

  • Janssen CarePath: Patient assistance program for eligible patients
  • Eligibility: Varies by insurance type and income
  • Apply: JanssenCarePath.com or call 1-877-227-3728

Additional Resources

  • Patient Advocate Foundation: Copay relief program for chronic diseases
  • Ohio pharmaceutical assistance programs: Contact Ohio Department of Commerce for state-specific programs

Frequently Asked Questions

Q: How long does Humana prior authorization take for Stelara in Ohio? A: Standard PA decisions come within 72 hours. Expedited reviews (when delay could jeopardize health) are decided within 24 hours.

Q: What if Stelara isn't on my Humana formulary? A: You can request a formulary exception with medical necessity documentation. Your prescriber must show preferred alternatives are inappropriate for your condition.

Q: Can I get an expedited appeal in Ohio? A: Yes, if delays would seriously jeopardize your health. Both Humana internal appeals and Ohio external reviews offer expedited timelines (24-72 hours vs. 7-30 days).

Q: Does step therapy reset if I switch from another state to Ohio? A: No, your prior therapy history follows you. Document all previous biologics tried, including those prescribed out-of-state.

Q: What's the difference between Part B and Part D coverage for Stelara? A: IV induction doses are covered under Medicare Part B (administered in clinic). Maintenance subcutaneous injections fall under Part D (specialty pharmacy delivery).

Q: Who can help me navigate the Ohio external review process? A: Contact the Ohio Department of Insurance Consumer Services at 800-686-1526 for guidance on filing and required forms.

When to Contact Ohio Regulators

Contact the Ohio Department of Insurance if:

  • Humana refuses to process your appeal or external review request
  • You're told you're not eligible for external review (ODI can independently determine eligibility)
  • Appeal deadlines aren't being met
  • You need help understanding your rights under Ohio insurance law

Consumer hotline: 800-686-1526
Online complaint portal: Available on ODI website

For complex cases involving specialty biologics like Stelara, consider working with a healthcare coverage specialist. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice, legal counsel, or a guarantee of coverage. Insurance policies, formularies, and state regulations change frequently. Always verify current requirements with your insurer and consult healthcare professionals for medical decisions. For personalized assistance with complex appeals, consider consulting with healthcare coverage specialists or patient advocacy organizations.

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