By Counterforce Health Team in Stelara (ustekinumab) —

Myths vs. Facts: Getting Stelara (Ustekinumab) Covered by Aetna CVS Health in Illinois

Answer Box: The Truth About Getting Stelara Covered in Illinois

Myth-busting reality: Your doctor's prescription alone doesn't guarantee Aetna CVS Health coverage for Stelara (ustekinumab). Success requires meeting specific prior authorization criteria, including tuberculosis screening, documented treatment failures, and specialist attestation. Illinois patients have strong appeal rights—including automatic external review for medical necessity denials starting in 2025. First step: Contact Aetna at 1-888-632-3862 to confirm your plan's exact requirements and submit a complete prior authorization with all supporting documentation.

Table of Contents

  1. Why These Myths Persist
  2. Common Myths vs. Facts
  3. What Actually Influences Approval
  4. Top 5 Preventable Mistakes
  5. Quick Action Plan
  6. Illinois Appeals Process
  7. Resources and Support

Why These Myths Persist

Confusion about Stelara coverage stems from the complexity of specialty drug approvals and varying insurance policies. Many patients assume that FDA approval equals automatic insurance coverage, or that expensive medications are always covered without restrictions. The reality is more nuanced—Aetna CVS Health requires prior authorization for Stelara across all indications, with specific clinical criteria that must be met.

These misconceptions can delay treatment and create unnecessary stress. Understanding the facts helps patients and providers navigate the approval process more effectively.

Common Myths vs. Facts

Myth 1: "If my doctor prescribes Stelara, Aetna has to cover it"

Fact: Prescription alone doesn't guarantee coverage. Aetna requires prior authorization with documented evidence of medical necessity, including failed prior treatments and specialist involvement.

Myth 2: "I can start treatment while waiting for approval"

Fact: Starting Stelara without prior authorization typically results in claim denials and full patient responsibility for costs. The medication must be precertified before administration, especially for infusion therapies.

Myth 3: "Tuberculosis screening is optional if I'm healthy"

Fact: TB screening is mandatory for all new Stelara patients. Most insurers require a negative TB test (TST or IGRA) within 12 months of initiation, regardless of risk factors.

Myth 4: "Generic medications work the same, so I don't need the brand"

Fact: Stelara (ustekinumab) is a biologic with no generic equivalent. Biosimilars may become available, but they require separate approval and may have different coverage policies.

Myth 5: "Appeals take forever and rarely succeed"

Fact: In Illinois, 52% of external reviews overturned insurer denials in 2024. Standard appeals must be decided within 30 days, and expedited appeals within 72 hours.

Myth 6: "I need to try every other medication first"

Fact: While step therapy is common, contraindications or documented intolerances to preferred agents can bypass these requirements. Clear documentation of why alternatives aren't suitable is key.

Myth 7: "Specialty pharmacies make the process harder"

Fact: CVS Specialty Pharmacy is often required for Stelara and provides dedicated support for prior authorizations and appeals, including clinical coordination services.

Myth 8: "If denied once, I can't try again"

Fact: You can appeal denials and resubmit with additional documentation. Illinois law provides multiple appeal levels, including binding external review.

What Actually Influences Approval

Clinical Documentation Requirements

Disease Severity: For psoriasis, insurers typically require moderate-to-severe disease affecting ≥10% body surface area or crucial areas like hands, feet, or scalp. For Crohn's disease, documentation must show moderate-to-severe active disease with inadequate response to conventional therapy.

Treatment History: Prior authorization policies require documented failure, intolerance, or contraindication to first-line treatments. This includes at least 3 months of systemic therapy (methotrexate, cyclosporine) for psoriasis, or TNF inhibitors for inflammatory bowel disease.

Specialist Involvement: Coverage often requires prescribing by a board-certified specialist—dermatologist for psoriasis, gastroenterologist for Crohn's disease, or rheumatologist for psoriatic arthritis.

Required Screening and Safety Documentation

  • Tuberculosis screening: Negative TB test within 12 months
  • Hepatitis B screening: Required by most plans
  • Infection clearance: No active infections at initiation
  • Concurrent therapy review: Documentation that patient isn't receiving other biologics
Clinician Corner: Medical necessity letters should include specific ICD-10 codes, prior medication names with dates and outcomes, current disease severity scores, and citations to relevant treatment guidelines. The FDA labeling provides approved indications and dosing that support coverage requests.

Top 5 Preventable Mistakes

1. Incomplete Prior Authorization Submissions

The Problem: Missing TB screening results, incomplete treatment history, or lack of specialist documentation. The Fix: Use Aetna's precertification checklist and submit all required documents simultaneously.

2. Starting Treatment Before Approval

The Problem: Assuming coverage while awaiting determination leads to claim denials. The Fix: Wait for written approval or use manufacturer patient assistance programs for temporary access.

3. Not Understanding Step Therapy Requirements

The Problem: Failing to document why preferred alternatives aren't appropriate. The Fix: Provide detailed records of prior treatment failures, including specific medications, doses, duration, and reasons for discontinuation.

4. Missing Appeal Deadlines

The Problem: Illinois requires external review requests within 4 months of final denial. The Fix: Track all deadlines and submit appeals promptly with complete documentation.

5. Inadequate Denial Response

The Problem: Generic appeals that don't address specific denial reasons. The Fix: Review the denial letter carefully and provide targeted responses to each cited concern.

Quick Action Plan

Step 1: Verify Coverage Requirements (Do Today)

  • Call Aetna member services at 1-888-632-3862
  • Confirm your plan's formulary status for Stelara
  • Request specific prior authorization requirements
  • Ask about step therapy obligations

Step 2: Gather Required Documentation (This Week)

  • Recent TB screening results (within 12 months)
  • Complete treatment history with dates and outcomes
  • Current lab results and imaging studies
  • Specialist consultation notes
  • Previous denial letters if applicable

Step 3: Submit Complete Prior Authorization (Within 2 Weeks)

  • Use Aetna's provider portal or designated forms
  • Include all supporting documentation
  • Request expedited review if clinically urgent
  • Follow up within 5 business days to confirm receipt

Illinois Appeals Process

Internal Appeals with Aetna

  • Deadline: 180 days from denial notification
  • Timeline: 15 days for standard appeals, 72 hours for urgent
  • Submission: Phone (1-866-235-5660), fax (1-855-633-7673), or online portal
  • Requirements: Explicit statement that submission is an appeal, complete patient information, clinical justification

External Review (Illinois Department of Insurance)

Starting in 2025, Illinois automatically refers medical necessity denials to external review unless patients opt out.

  • Eligibility: Medical necessity, appropriateness, effectiveness determinations
  • Timeline: 30 days total, with reviewer decision within 5 days of receiving documentation
  • Cost: Free to patients
  • Outcome: Binding decision on insurer

Consumer Assistance

The Illinois Department of Insurance OCHI helpline (1-877-527-9431) provides free assistance with appeals and external review applications.

Resources and Support

When navigating complex insurance approvals for specialty medications like Stelara, having the right support can make all the difference. 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 create compelling rebuttals aligned with each payer's specific requirements.

Official Resources

Patient Assistance Programs

  • Janssen CarePath: Copay support and free drug programs
  • Patient Access Network Foundation: Grants for eligible patients
  • HealthWell Foundation: Disease-specific assistance funds

Advocacy Support

For complex cases requiring additional support, Counterforce Health provides specialized appeal assistance that addresses payer-specific workflows and produces documentation that meets procedural requirements while tracking deadlines and required attachments.

From Our Advocates: "We've seen Stelara denials overturned when patients submitted TB screening from 13 months prior—just one month past the typical 12-month requirement. The key was having the prescribing physician write a letter explaining why the slightly older test was still clinically valid, combined with a current chest X-ray. This type of targeted response to specific denial reasons often makes the difference between approval and continued delays."

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may vary by plan and change over time. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation. For official Illinois insurance regulations and consumer assistance, visit idoi.illinois.gov.

Sources & Further Reading

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