By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by UnitedHealthcare in Ohio: Prior Authorization Guide, Appeal Forms, and Timeline

Quick Answer: Getting Stelara Covered by UnitedHealthcare in Ohio

Fastest path to approval: Submit prior authorization through UHC's provider portal with documented moderate-to-severe disease, prior therapy failures (including preferred biosimilars), and recent TB screening. If denied, file internal appeal within 180 days, then Ohio external review if needed. Start today: Call UHC member services to confirm formulary status and PA requirements for your specific plan.

Table of Contents

  1. UnitedHealthcare Policy Overview
  2. Stelara Coverage Requirements by Condition
  3. Step Therapy and Biosimilar Requirements
  4. Prior Authorization Documentation
  5. Common Denial Reasons and Solutions
  6. Appeals Process in Ohio
  7. Site of Care Requirements for IV Infusions
  8. Costs and Patient Assistance
  9. Frequently Asked Questions

UnitedHealthcare Policy Overview

UnitedHealthcare requires prior authorization for Stelara (ustekinumab) across all plan types in Ohio, including commercial, Medicare Advantage, and Medicaid managed care plans. The approval process involves both clinical criteria and formulary positioning.

Plan Types and Coverage Differences

  • Commercial Plans: Subject to UHC's commercial medical benefit drug policy with 12-month authorization periods
  • Medicare Advantage: Similar clinical criteria with expedited appeal options
  • Medicaid (Community Plan): Additional state requirements and external medical review options
Important: As of September 2024, UnitedHealthcare has removed brand Stelara from many commercial formularies, requiring members to try preferred ustekinumab biosimilars (Steqeyma, Yesintek) first.

Stelara Coverage Requirements by Condition

Moderate-to-Severe Plaque Psoriasis

Required Documentation:

  • Diagnosis with ICD-10 code (L40.0/L40.9)
  • Body surface area (BSA) ≥10% or PASI score ≥10
  • Involvement of face, scalp, hands, feet, or genitals
  • Failed topical therapies and phototherapy
  • Weight-based dosing justification (45mg for ≤100kg, 90mg for >100kg)

Psoriatic Arthritis

Clinical Criteria:

  • Active psoriatic arthritis diagnosis
  • Failed conventional DMARD (methotrexate, sulfasalazine, leflunomide)
  • Often requires prior TNF inhibitor trial
  • Documented joint symptoms and functional impairment

Crohn's Disease and Ulcerative Colitis

Step Therapy Requirements:

  • Moderate-to-severe disease confirmed by endoscopy
  • Failed corticosteroids and immunomodulators
  • Prior anti-TNF therapy (adalimumab, infliximab) typically required
  • Recent inflammatory markers (CRP, fecal calprotectin)

Step Therapy and Biosimilar Requirements

Biosimilar-First Policy

UnitedHealthcare's 2025 formulary changes require:

  1. Trial of preferred biosimilars (Steqeyma or Yesintek) before brand Stelara
  2. Medical exception for brand Stelara only with documented:
    • Failure or adverse reaction to both preferred biosimilars
    • Clinical reasons why switching is inappropriate

Medical Exception Criteria

To obtain brand Stelara over biosimilars, document:

  • Specific dates and nature of biosimilar failure
  • Adverse reactions with details and severity
  • Clinical stability concerns with switching
Tip: Existing Stelara users may need to switch or file exceptions when coverage renews, even if previously stable on therapy.

Prior Authorization Documentation

Essential Clinical Information

For All Indications:

  • Specific diagnosis and ICD-10 code
  • Disease severity with objective measures
  • Complete prior therapy history with outcomes
  • Recent tuberculosis screening (QuantiFERON or PPD within 6-12 months)
  • Current weight for dosing justification
  • Prescriber specialty confirmation

Medical Necessity Letter Template

Your clinician's letter should include:

  1. Patient identification and diagnosis
  2. Disease severity and impact on daily function
  3. Prior treatments tried with specific drugs, doses, durations, and reasons for discontinuation
  4. Why Stelara is medically necessary for this patient
  5. Monitoring plan and expected outcomes

Counterforce Health helps clinicians draft targeted, evidence-backed medical necessity letters that address UnitedHealthcare's specific criteria. The platform ingests denial letters and plan policies to create point-by-point rebuttals aligned to UHC's own rules, significantly improving approval rates.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Step therapy not satisfied Document biosimilar failures Specific dates, doses, adverse reactions
Insufficient severity Provide objective measures PASI, BSA, joint counts, endoscopy
Missing TB screening Submit recent test results QuantiFERON/PPD within 6-12 months
Non-formulary drug Request medical exception Biosimilar intolerance evidence
Quantity limits exceeded Justify dosing frequency Clinical response data, guidelines

TB Screening Requirements

Acceptable Tests:

  • QuantiFERON-TB Gold
  • T-Spot tuberculosis test
  • Tuberculin skin test (PPD)

If Positive: Include documentation of latent TB treatment completion and infectious disease clearance.

Appeals Process in Ohio

Internal Appeals with UnitedHealthcare

Timeline: 30 days for standard appeals, 72 hours for urgent cases

Required Steps:

  1. File written appeal through UHC member portal or mail
  2. Include updated medical records and prescriber letter
  3. Request expedited review if delay poses health risks

Ohio External Review Process

If UHC denies your internal appeal, Ohio law provides external review through an Independent Review Organization (IRO).

Key Details:

  • Deadline: 180 days from final UHC denial
  • Cost: Free to patients
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Decision: Binding on UnitedHealthcare

How to Request:

  1. Submit written request through UnitedHealthcare (not directly to Ohio DOI)
  2. Include final denial letter and signed medical records release
  3. Send additional evidence to assigned IRO within 10 business days
Contact: Ohio Department of Insurance Consumer Services: 1-800-686-1526

Site of Care Requirements for IV Infusions

Preferred Settings

UnitedHealthcare's site-of-care policy encourages Stelara IV infusions in:

  • Physician offices
  • Ambulatory infusion suites
  • Home infusion (when appropriate)

Hospital Outpatient Approval

Limited to 6 months with medical necessity for:

  • Cardiovascular instability requiring hospital monitoring
  • History of severe infusion reactions
  • Complex vascular access needs
  • Cognitive/physical impairments making other settings unsafe

Costs and Patient Assistance

Insurance Coverage

  • Commercial plans: Typically specialty tier with 20-40% coinsurance
  • Medicare: Part B coverage for IV induction, Part D for maintenance
  • Medicaid: Covered with prior authorization

Patient Support Programs

  • Janssen CarePath: Copay assistance up to $20,000/year for eligible patients
  • Patient assistance programs for uninsured patients meeting income requirements

Counterforce Health also helps patients navigate insurance denials and appeals, turning rejections into successful approvals through evidence-based advocacy. Their platform tracks appeal deadlines and ensures all required documentation is included.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Ohio? Standard PA decisions: up to 15 days. Urgent requests: 24-72 hours when delay would jeopardize health.

What if Stelara is non-formulary on my plan? Request a medical exception with documented failure or intolerance to preferred biosimilars (Steqeyma, Yesintek).

Can I get expedited appeals in Ohio? Yes, for urgent cases where delay could seriously jeopardize health. Both UHC internal appeals and Ohio external review offer expedited timelines.

Do I need to try biosimilars if I'm already on Stelara? Possibly. UHC's formulary changes may require switching or filing medical exceptions even for stable patients at renewal.

What counts as "prior therapy failure" for step therapy? Documented inadequate response, loss of response, intolerance, or contraindication to required medications with specific dates, doses, and outcomes.

How do I find my specific UHC formulary? Check your plan documents or call member services. Formularies vary by plan type and may change annually.

What if my appeal is denied in Ohio? After exhausting UHC internal appeals, you have 180 days to request external review through Ohio's Independent Review Organization process.

Are there special requirements for pediatric patients? Stelara has limited pediatric approvals. Check FDA labeling and discuss age-appropriate alternatives with your physician.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan. Always verify current requirements with UnitedHealthcare and consult healthcare providers for medical decisions. For personalized assistance with complex appeals, Counterforce Health provides specialized support in navigating insurance denials and prior authorization challenges.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.