By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by Humana in Texas: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Stelara Covered by Humana in Texas

Humana requires prior authorization for Stelara (ustekinumab) in Texas, typically with step therapy requirements and specialty pharmacy dispensing. The fastest path: 1) Verify your plan's formulary tier and PA requirements using Humana's drug search tool, 2) Have your specialist submit a complete PA packet with diagnosis, severity scores, prior therapy failures, and TB screening, 3) If denied, file an internal appeal within 65 days with enhanced medical necessity documentation.

First step today: Call the number on your Humana ID card to confirm whether Stelara is covered under Part B (medical) or Part D (pharmacy) for your specific indication.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Monitoring
  6. Typical Timelines in Texas
  7. If You Need to Provide More Information
  8. If Your Request Is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This comprehensive guide helps patients and their healthcare providers navigate Humana's prior authorization process for Stelara (ustekinumab) in Texas. Whether you're dealing with moderate-to-severe plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis, we'll walk you through each step to maximize your chances of approval.

Who this helps:

  • Texas residents with Humana Medicare Advantage, Part D, or commercial plans
  • Clinicians submitting prior authorization requests
  • Patients facing denials who need to appeal

You'll get a clear roadmap from initial submission through the appeals process, with specific forms, timelines, and contact information for Texas.

Before You Start: Verify Your Coverage

Confirm Your Plan Type and Formulary Status

Before submitting any paperwork, you need to understand exactly how your Humana plan covers Stelara.

Step 1: Check if Stelara is on your formulary

Step 2: Determine benefit type

  • IV induction doses (for Crohn's/UC): Usually covered under Part B as a medical benefit
  • Subcutaneous maintenance: Typically Part D pharmacy benefit through specialty pharmacy

Step 3: Identify your specialty pharmacy options

  • Humana often requires CenterWell Specialty Pharmacy for biologics
  • Check your plan's pharmacy directory for in-network specialty pharmacies in Texas
Note: Humana's 2026 formularies show Stelara as Tier 5 (specialty) with lower-tier biosimilar alternatives like Otulfi and Yesintek that may be required first.

Gather Required Documentation

Essential Clinical Documentation

Your specialist's office needs to compile comprehensive documentation before submitting the PA request:

Diagnosis and Severity Measures

  • ICD-10 code for your specific condition
  • Objective severity scores:
    • Psoriasis: PASI score ≥10, BSA ≥10%, or DLQI score
    • Crohn's disease: CDAI score, Harvey-Bradshaw Index, or Mayo score
    • Psoriatic arthritis: Joint counts, functional assessments

Prior Treatment History Document each previous therapy with:

  • Exact medication names and doses
  • Start and stop dates
  • Duration of treatment
  • Reason for discontinuation (inadequate response, intolerance, contraindication)

Safety Screening Requirements

  • TB screening (QuantiFERON or TST) within 6-12 months
  • Hepatitis B and C serology
  • Complete blood count and liver function tests

Medical Necessity Documentation

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to the plan's own rules.

Your medical necessity letter should address:

  • Why conventional therapies are inadequate or contraindicated
  • Specific clinical goals (PASI reduction, mucosal healing, steroid reduction)
  • Why Stelara is preferred over formulary alternatives
  • Treatment and monitoring plan

Submit Your Prior Authorization Request

Submission Channels

For Part D (Pharmacy Benefit)

For Part B (Medical Benefit)

Complete Request Packet Checklist

□ Completed Humana PA form (plan-specific) □ Specialist consultation note with diagnosis □ Objective severity measurements □ Complete prior therapy documentation □ TB screening results □ Baseline safety labs □ Medical necessity letter □ Planned dosing regimen

Follow-Up and Monitoring

When and How to Check Status

Timeline for follow-up:

  • Day 3: Check submission receipt
  • Day 5: Verify all documents received
  • Day 7: Request status update if no decision

Sample call script: "I'm calling to check the status of a prior authorization request for Stelara (ustekinumab) submitted on [date] for patient [name], member ID [number]. Can you confirm if any additional information is needed?"

Document everything:

  • Reference numbers from calls
  • Names of representatives
  • Dates and times of contact
  • Any additional requests

Typical Timelines in Texas

Standard Decision Timeframes

Benefit Type Standard Decision Expedited Decision Appeal Timeline
Part D (Pharmacy) 72 hours 24 hours 7 days (Level 1)
Part B (Medical) 30 days 72 hours 30 days (Level 1)
External Review 20 days 5 days 45 days to file

Texas-specific protections:

  • Internal appeals must be filed within 180 days of denial
  • External review available through Texas Department of Insurance IRO process
  • Expedited external review for urgent cases (5 days vs. 20 days standard)

If You Need to Provide More Information

Common Information Requests

Medical necessity clarification:

  • More detailed severity scores
  • Additional prior therapy documentation
  • Contraindication explanations for preferred agents

Safety documentation:

  • Updated TB screening if older than 12 months
  • Recent lab results
  • Specialist clearance for comorbidities

Response Strategy

Respond to information requests within 24-48 hours to avoid delays. Include:

  • Clear cover letter addressing each specific question
  • Organized supporting documentation
  • Updated medical necessity rationale if needed

If Your Request Is Denied

Understanding Denial Reasons

Common denial codes:

  • Step therapy not completed
  • Insufficient documentation of severity
  • Lack of prior therapy failures
  • Safety concerns not addressed

Internal Appeals Process

Level 1 Appeal (Redetermination)

  • Deadline: 65 days from denial notice
  • Timeline: 7 days for Part D, 30 days for Part B
  • Required: Enhanced medical necessity letter addressing each denial reason

Level 2 Appeal (Independent Review)

  • Deadline: 60 days from Level 1 denial
  • Timeline: 7 days for Part D benefit appeals
  • Process: Independent Review Entity (IRE) review

Texas External Review Rights

If internal appeals fail, Texas residents can request external review through the Texas Department of Insurance IRO process for state-regulated plans. Note that Medicare plans follow federal appeal procedures.

Contact for assistance:

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742

Renewal and Re-Authorization

Planning for Continuation

Most Humana plans require annual re-authorization for Stelara. Calendar renewal 60-90 days before your current authorization expires.

Renewal documentation:

  • Updated disease activity scores
  • Treatment response documentation
  • Continued medical necessity justification
  • Any new contraindications to alternatives

Streamlined Renewal Process

Patients stable on Stelara may qualify for expedited renewal if:

  • No significant adverse events
  • Documented clinical improvement
  • No new preferred alternatives available

Quick Reference Checklist

Before submitting: □ Verify formulary status and tier □ Confirm Part B vs. Part D coverage □ Identify required specialty pharmacy □ Check for step therapy requirements

Documentation packet: □ Complete PA form □ Diagnosis with ICD-10 code □ Objective severity scores □ Prior therapy failures documented □ TB screening (within 12 months) □ Medical necessity letter

After submission: □ Document reference numbers □ Follow up within 3-5 days □ Respond quickly to information requests □ Prepare appeal materials if denied

Frequently Asked Questions

Q: How long does Humana prior authorization take in Texas? A: Standard Part D requests: 72 hours. Part B requests: up to 30 days. Expedited requests can be processed within 24-72 hours if clinical urgency is documented.

Q: What if Stelara is non-formulary on my plan? A: Request a formulary exception with enhanced medical necessity documentation. Include contraindications to formulary alternatives and guideline support for Stelara.

Q: Can I request expedited review for Stelara? A: Yes, if your prescriber documents that delay would seriously jeopardize your health or ability to regain maximum function. This is common for active inflammatory conditions.

Q: Does Texas step therapy apply to patients who've failed treatments in other states? A: Yes, documented treatment failures from any state count toward step therapy requirements. Ensure complete documentation from previous providers.

Q: What specialty pharmacies does Humana use in Texas? A: CenterWell Specialty Pharmacy is Humana's preferred provider. Check your plan's pharmacy directory for other in-network specialty pharmacies in your area.

Q: How much will Stelara cost with Humana coverage? A: Costs vary by plan. Specialty tier medications typically have higher copays or coinsurance. Contact your plan for specific cost-sharing information.

When navigating complex prior authorization requirements, Counterforce Health helps patients and clinicians by analyzing denial patterns and creating targeted appeals that address specific payer criteria and procedural requirements.

Disclaimer: This guide provides general information about insurance processes and should not replace professional medical advice. Coverage policies and procedures may vary by specific plan and change over time. Always consult with your healthcare provider and insurance plan for the most current requirements.

Sources & Further Reading

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