By Counterforce Health Team in Stelara (ustekinumab) —

How to Get Stelara (Ustekinumab) Covered by UnitedHealthcare in Washington: Complete Guide to Prior Authorization, Appeals, and Medical Necessity Letters

Answer Box: Your Path to Stelara Coverage in Washington

UnitedHealthcare requires prior authorization for brand Stelara (ustekinumab) with step therapy through biosimilars first. In Washington, if denied, you have 180 days for internal appeals plus external review through an Independent Review Organization. Start today: Have your doctor submit a medical necessity letter documenting biosimilar failures or contraindications, include severity scores (PASI ≥12 for psoriasis, CDAI >220 for Crohn's), and request peer-to-peer review if initially denied.

Table of Contents

  1. Understanding UnitedHealthcare's Stelara Requirements
  2. Preparing for Your Doctor Visit
  3. Building Your Clinical Evidence Kit
  4. Medical Necessity Letter Essentials
  5. Peer-to-Peer Review Support
  6. Appeals Process in Washington
  7. When to Escalate and Get Help
  8. FAQ

Understanding UnitedHealthcare's Stelara Requirements

UnitedHealthcare classifies brand Stelara as a non-formulary specialty biologic, prioritizing biosimilars (Steqeyma, Wezlana, Yesintek) through step therapy. Coverage requires prior authorization with approval lasting 12 months.

Coverage Criteria at a Glance

Requirement What It Means Documentation Needed
Biosimilar Step Therapy Must try preferred alternatives first Allergy/intolerance to ALL biosimilars OR prior Stelara success + 2 biosimilar failures (≥6 weeks each)
Indication Approval FDA-approved conditions only ICD-10 codes: L40.0 (psoriasis), K50.00 (Crohn's), K51.90 (UC), L40.52 (psoriatic arthritis)
Severity Documentation Moderate-to-severe disease PASI ≥12 or BSA >10% (psoriasis); CDAI >220 (Crohn's); endoscopy/colonoscopy results
Infection Screening TB and hepatitis clearance Negative TB test, HBV/HCV screening within 6 months
Note: UnitedHealthcare's PA denial rate for specialty drugs runs higher than peer averages, making thorough documentation crucial from the start.

Preparing for Your Doctor Visit

Your partnership with your prescribing physician—whether a dermatologist, gastroenterologist, or rheumatologist—is essential for navigating UnitedHealthcare's requirements.

What to Bring to Your Appointment

Symptom Timeline (Last 2 Years)

  • Disease flares and severity
  • Functional impact on work, relationships, daily activities
  • Photos of skin lesions or joint swelling (if applicable)
  • Hospitalizations or ER visits

Treatment History Documentation

  • Complete list of medications tried with:
    • Exact names and doses
    • Duration of treatment
    • Reason for discontinuation (ineffective, side effects, contraindications)
    • Documentation of adequate trials (typically 12-16 weeks for biologics)

Current Insurance Information

  • UnitedHealthcare member ID
  • Group number and plan type (commercial, Medicare Advantage, etc.)
  • Prior authorization forms if already initiated

Questions to Ask Your Doctor

  1. "Can you document why biosimilars aren't appropriate for my case?"
  2. "What severity scores support my need for Stelara?"
  3. "Will you be available for a peer-to-peer review if we're initially denied?"
  4. "Can we submit the PA before my next appointment to avoid treatment delays?"

Building Your Clinical Evidence Kit

Strong clinical documentation dramatically improves approval odds. Counterforce Health helps patients and clinicians turn denials into targeted appeals by identifying exactly what evidence payers need and drafting point-by-point rebuttals aligned to plan policies.

Essential Lab Work and Testing

Required Screening (Within 6 Months)

  • TB testing: TST or IGRA (QuantiFERON)
  • Hepatitis panel: HBsAg, anti-HBc, anti-HBs, HCV antibody
  • Complete blood count with differential
  • Liver function tests

Disease-Specific Evidence

  • Psoriasis: PASI score, body surface area calculation, dermatology photos
  • Crohn's Disease: CDAI score, recent colonoscopy/CT enterography, CRP/ESR levels
  • Ulcerative Colitis: Mayo score, sigmoidoscopy results, stool frequency logs
  • Psoriatic Arthritis: Joint count, enthesitis assessment, imaging of affected joints

Guideline Support

Reference these authoritative sources in your medical necessity letter:

  • FDA prescribing information for approved indications
  • ACR guidelines for psoriatic arthritis treatment
  • AAD guidelines for moderate-to-severe psoriasis
  • AGA guidelines for inflammatory bowel disease

Medical Necessity Letter Essentials

Your doctor's medical necessity letter is the cornerstone of approval. Use Janssen's template as a starting point, but customize for UnitedHealthcare's specific criteria.

Required Letter Components

Header Section

  • Patient demographics and UnitedHealthcare member ID
  • Diagnosis with ICD-10 code
  • Requested medication: Stelara (ustekinumab) with specific dosing
  • Prescriber credentials and DEA number

Clinical Rationale

  • Disease duration and current severity
  • Functional impairment and quality of life impact
  • Prior therapy failures with specific details:
    • Drug names, doses, duration
    • Reason for discontinuation
    • Documentation of adequate trials

Biosimilar Exception Justification Document one of these scenarios:

  • Documented allergy or intolerance to inactive ingredients in ALL biosimilars (Steqeyma, Wezlana, Yesintek)
  • Prior successful treatment with brand Stelara AND documented failure of two biosimilars after ≥6 weeks each

Supporting Evidence

  • Recent lab results and imaging
  • Severity scores and objective measures
  • Guideline citations supporting Stelara use
  • Prognosis without treatment
Clinician Corner: Include specific policy language from UnitedHealthcare's non-formulary Stelara policy to demonstrate you're addressing their exact criteria.

Peer-to-Peer Review Support

If your initial PA is denied, request a peer-to-peer review immediately. This allows your doctor to speak directly with a UnitedHealthcare medical director about your case.

Preparing Your Doctor for the Call

Key Talking Points

  • Specific biosimilar contraindications or documented failures
  • Objective severity measures that meet moderate-to-severe criteria
  • Functional impairment documentation
  • Risk of disease progression without treatment

Timeline Management

  • Request peer-to-peer within 5-7 business days of denial
  • Offer flexible scheduling to accommodate the reviewer's availability
  • Have all clinical documentation readily available during the call

Documentation During the Call

  • Take notes on the reviewer's specific concerns
  • Ask for clarification on any additional evidence needed
  • Request written confirmation of any verbal approvals

Appeals Process in Washington

Washington provides robust consumer protections for insurance denials. If your initial PA and peer-to-peer review are unsuccessful, you have multiple appeal levels with specific deadlines.

Internal Appeals (UnitedHealthcare)

Level 1 Appeal

  • Deadline: 180 days from denial date
  • Timeline: UnitedHealthcare has 30 days to decide (72 hours for urgent cases)
  • Submission: Via UnitedHealthcare provider portal or fax (verify current number)

Required Documentation

  • Copy of original denial letter
  • Updated medical necessity letter addressing denial reasons
  • Any new clinical evidence or test results
  • Clear statement: "Appeal - Medical Necessity for Stelara"

External Review (Washington State)

If UnitedHealthcare upholds the denial, Washington's external review process (RCW 48.43.535) provides an independent assessment.

Key Details

  • Cost: Free to you
  • Deadline: 4 months from final internal denial
  • Decision Timeline: 45 days for standard review, 72 hours for expedited
  • Binding: Decision is legally binding on UnitedHealthcare

How to File

  1. Contact Washington Office of the Insurance Commissioner: 1-800-562-6900
  2. Submit written request with denial documentation
  3. Provide all medical records supporting your case
  4. Independent Review Organization (IRO) reviews and decides
From Our Advocates: We've seen Washington patients successfully overturn UnitedHealthcare denials for specialty biologics through external review, especially when the clinical documentation clearly demonstrates biosimilar failures or contraindications. The key is providing comprehensive medical records that tell your complete treatment story.

When to Escalate and Get Help

State Resources

Washington Office of the Insurance Commissioner

  • Consumer Advocacy: 1-800-562-6900
  • Website: insurance.wa.gov
  • Services: Appeal guidance, complaint filing, IRO coordination

When to Contact OIC

  • UnitedHealthcare misses appeal deadlines
  • Denial reasons seem inconsistent with policy
  • Need help understanding your appeal rights
  • Procedural issues with external review

Professional Support

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying missing criteria, and drafting evidence-backed rebuttals that speak directly to payer policies. Their platform helps patients and clinicians navigate complex prior authorization requirements with higher success rates.

Additional Resources

  • Patient advocate organizations for your condition
  • Hospital financial counselors
  • Legal aid societies for insurance disputes

FAQ

How long does UnitedHealthcare prior authorization take for Stelara in Washington? Standard PA decisions come within 72 hours. Urgent requests (when delay could jeopardize health) get 24-hour turnaround. If no response within these timeframes, the request is automatically approved.

What if Stelara isn't on UnitedHealthcare's formulary? Stelara is non-formulary for most UnitedHealthcare plans, requiring step therapy through biosimilars first. You can request an exception with documented biosimilar failures or contraindications.

Can I request an expedited appeal if I'm currently on Stelara? Yes, if discontinuing treatment could seriously jeopardize your health. Document current stability on Stelara and risks of interruption. Expedited appeals get 72-hour decisions.

Does step therapy apply if I failed biosimilars in another state? Yes, documented biosimilar failures from other states count toward UnitedHealthcare's step therapy requirements. Ensure your new doctor has complete treatment records.

What's the success rate for Stelara appeals in Washington? While specific data isn't published, Washington's external review process overturns about 40% of insurer denials nationwide. Strong clinical documentation significantly improves your odds.

How much does Stelara cost without insurance? Stelara costs approximately $12,000-15,000 annually. Janssen offers patient assistance programs and copay cards that may reduce out-of-pocket costs significantly.

Can I use Optum Specialty Pharmacy for appeals support? If you're using Optum Specialty Pharmacy, their Appeals Team can help draft appeal letters and provide peer-to-peer talking points. They report an ~80% overturn rate for previously denied cases.

What happens if the external review upholds UnitedHealthcare's denial? The external review decision is final for your insurance appeal. However, you may still have options through manufacturer assistance programs, clinical trials, or seeking care through a different insurance plan during open enrollment.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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