By Counterforce Health Team in Stelara (ustekinumab) —

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

Answer Box: Getting Stelara (ustekinumab) covered by Aetna CVS Health in Michigan requires prior authorization with documented step therapy failure and TB screening. The fastest path: 1) Submit complete PA request with specialist prescription and prior treatment history, 2) If denied, file internal appeal within 180 days, 3) Request Michigan DIFS external review within 127 days of final denial. Start by calling Aetna at 1-866-752-7021 or using your provider portal today.

Table of Contents

Why Myths About Stelara Coverage Persist

Stelara (ustekinumab) coverage myths spread because the prior authorization process is complex and varies by plan. Patients often hear conflicting information from different sources—pharmacy staff, insurance representatives, and even healthcare providers may not have the latest Aetna policy details.

The reality is that Aetna CVS Health has specific, documented requirements for Stelara approval that vary by indication (psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis). Understanding these facts can save you months of delays and thousands of dollars in out-of-pocket costs.

Counterforce Health helps patients navigate these complexities by turning insurance denials into targeted, evidence-backed appeals. Their platform ingests denial letters and plan policies to draft point-by-point rebuttals aligned to the plan's own rules, significantly improving approval rates.

Common Myths Debunked

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

Fact: Prior authorization is required for all Aetna plans. Even with a prescription, you need documented medical necessity and step therapy compliance before approval.

Myth 2: "Step therapy doesn't apply if I'm switching from another biologic"

Fact: Aetna requires documented failure, intolerance, or contraindication to preferred alternatives like methotrexate for psoriatic arthritis, regardless of your biologic history. The policy is clear—prior biologic use doesn't automatically exempt you from conventional therapy requirements.

Myth 3: "TB screening is just a formality"

Fact: Tuberculosis screening is mandatory and must be documented as negative within 12 months before starting Stelara. Missing or incomplete TB screening is a common denial reason.

Myth 4: "Any doctor can prescribe Stelara for approval"

Fact: Aetna requires specialist involvement—rheumatologist or dermatologist for psoriatic arthritis, gastroenterologist for IBD conditions. Primary care prescriptions are typically denied.

Myth 5: "Appeals take forever and rarely work"

Fact: Michigan external reviews through DIFS are decided within 60 days for standard appeals, 72 hours for expedited cases. Success rates improve significantly with proper documentation.

Myth 6: "Biosimilars are automatically preferred over Stelara"

Fact: While Aetna may prefer biosimilars like Yesintek, medical necessity documentation can support brand-name Stelara if clinically appropriate.

Myth 7: "Prior authorization is just a delay tactic"

Fact: PA serves legitimate clinical and cost management purposes. Understanding Aetna's specific criteria and submitting complete documentation typically results in faster approvals.

What Actually Influences Approval

Clinical Documentation Requirements

  • Diagnosis confirmation with ICD-10 codes
  • Disease severity documentation (body surface area for psoriasis, disease activity scores for IBD)
  • Prior treatment history with specific medications, dosing, duration, and outcomes
  • Contraindications or intolerances to preferred alternatives

Specialist Involvement

Aetna requires prescriptions from appropriate specialists:

  • Psoriasis/Psoriatic Arthritis: Dermatologist or rheumatologist
  • Crohn's Disease/Ulcerative Colitis: Gastroenterologist

Laboratory Requirements

  • TB screening: Negative TST, IGRA, or chest X-ray within 12 months
  • Inflammatory markers: CRP, ESR for ongoing monitoring
  • Disease-specific labs: Fecal calprotectin for IBD, liver function tests

Insurance-Specific Factors

  • Formulary tier: Stelara is typically Tier 4 or 5 (specialty)
  • Quantity limits: Monthly supply restrictions apply
  • Site of care: Some indications require specialty pharmacy dispensing

Mistakes to Avoid

1. Incomplete Prior Authorization Submission

Missing clinical notes, lab results, or treatment history leads to automatic denials. Use Aetna's PA form as a checklist.

2. Wrong Prescriber Type

Primary care prescriptions are routinely denied. Ensure your specialist is the prescriber of record.

3. Inadequate Step Therapy Documentation

Simply listing prior medications isn't enough. Document specific doses, durations, and reasons for discontinuation.

4. Missing TB Screening

This mandatory requirement causes preventable denials. Complete screening before submitting your PA request.

5. Not Following Up on Pending Requests

PA requests can sit in queues without notification. Call Aetna at 1-866-752-7021 to check status after 5 business days.

Your Action Plan

Step 1: Gather Required Documentation (1-2 days)

  • Insurance card and member ID
  • Complete medical records for your condition
  • List of all prior treatments with dates and outcomes
  • Recent TB screening results
  • Specialist consultation notes

Step 2: Submit Prior Authorization (Same day)

  • Use Aetna's online provider portal for fastest processing
  • Alternatively, fax completed forms to 1-888-267-3277
  • Include all supporting documentation in initial submission

Step 3: Monitor and Follow Up (Ongoing)

  • Check status within 5 business days
  • Prepare appeal documentation if denied
  • Know your Michigan appeal rights and deadlines
From our advocates: We've seen cases where patients received approval within 48 hours by submitting complete documentation upfront, including detailed prior treatment timelines and specialist letters. The key is thoroughness in the initial submission rather than hoping to add information later.

Coverage Requirements at a Glance

Requirement Psoriasis Psoriatic Arthritis Crohn's Disease Ulcerative Colitis
Prior Authorization Required Required Required Required
Specialist Prescriber Dermatologist Rheumatologist/Dermatologist Gastroenterologist Gastroenterologist
Step Therapy Systemics/phototherapy Methotrexate/leflunomide Varies by plan Varies by plan
TB Screening Mandatory Mandatory Mandatory Mandatory
Disease Severity Moderate-severe Active disease Moderate-severe Moderate-severe
Formulary Tier Tier 4-5 Tier 4-5 Tier 4-5 Tier 4-5

Source: Aetna Clinical Policy Bulletin

Appeals Process for Michigan

Internal Appeals (Aetna)

  • Deadline: 180 days from denial
  • Timeline: 30 days for post-service, 15 business days for prior authorization
  • Expedited: 72 hours with physician attestation of urgency
  • How to file: Online portal, phone (1-866-752-7021), or fax

External Review (Michigan DIFS)

  • Deadline: 127 days after final internal denial
  • Timeline: 60 days standard, 72 hours expedited
  • Cost: Free to patients
  • How to file: DIFS online form or paper submission
  • Contact: 877-999-6442

The Michigan Department of Insurance and Financial Services provides binding external review decisions that Aetna must follow.

FAQ

Q: How long does Aetna prior authorization take for Stelara in Michigan? A: Standard PA decisions are made within 15 business days. Expedited requests require 72 hours with physician urgency documentation.

Q: What if Stelara isn't on my Aetna formulary? A: You can request a formulary exception with medical necessity documentation. Submit through the standard PA process with additional clinical justification.

Q: Can I get expedited approval if I'm switching from another biologic? A: Yes, if your physician documents that a delay would seriously jeopardize your health. Submit expedited PA request with supporting clinical rationale.

Q: Does step therapy apply if I failed treatments in another state? A: Yes, but document all prior treatments thoroughly. Out-of-state medical records are acceptable if they show adequate trials and failures.

Q: What happens if my appeal is denied? A: You can request external review through Michigan DIFS within 127 days. This independent review is binding on Aetna.

Q: Are there financial assistance programs for Stelara? A: Janssen offers patient assistance programs and copay cards. Contact their support line at 1-800-JANSSEN for eligibility screening.

Resources

Official Aetna Resources

Michigan State Resources

Patient Support

  • Counterforce Health - Insurance appeal assistance
  • Janssen CarePath: 1-800-JANSSEN
  • Patient Advocate Foundation: 1-800-532-5274

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your specific Aetna plan and consult healthcare providers for medical decisions. For official Michigan insurance appeal guidance, contact DIFS at 877-999-6442.

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