By Counterforce Health Team in Stelara (ustekinumab) —

Myths vs. Facts: Getting Stelara (ustekinumab) Covered by Blue Cross Blue Shield in Virginia - Appeals Guide 2025

Answer Box: Getting Stelara Covered by BCBS Virginia

Eligibility: BCBS Virginia (Anthem) requires prior authorization for Stelara with step therapy criteria—patients typically need documented failure of preferred biologics or contraindications. Fastest path: Submit complete PA request with TB screening, disease severity scores (PASI >10 for psoriasis, CDAI >220 for Crohn's), and prior therapy documentation. First step today: Call BCBS member services at the number on your card to confirm your plan's specific formulary tier and PA requirements, then download current forms from Anthem's provider portal.

Table of Contents

  1. Why Myths About Stelara Coverage Persist
  2. Common Myths vs. Facts
  3. What Actually Influences Approval
  4. Avoid These Critical Mistakes
  5. Quick Action Plan: Three Steps to Take Today
  6. Appeals Process in Virginia
  7. Resources and Support

Why Myths About Stelara Coverage Persist

Misinformation about getting Stelara (ustekinumab) covered by Blue Cross Blue Shield spreads quickly among patients dealing with psoriasis, psoriatic arthritis, and inflammatory bowel disease. These myths often stem from outdated information, confusion between different Blue plans, and the complexity of prior authorization requirements that vary significantly across the 36 independent Blue Cross Blue Shield plans.

In Virginia, where Anthem Blue Cross Blue Shield holds approximately 43% of the commercial insurance market, patients frequently encounter conflicting advice about coverage requirements. The stakes are high—Stelara can cost over $20,000 annually without insurance coverage, making accurate information critical for accessing this IL-12/23 inhibitor biologic.

Common Myths vs. Facts

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

Fact: Prior authorization is required for all Stelara prescriptions under BCBS Virginia plans. Anthem updated their PA requirements effective May 1, 2024 and July 1, 2024, meaning prescribers must submit clinical documentation and receive approval before coverage begins. A prescription alone doesn't guarantee coverage.

Myth 2: "Step therapy doesn't apply if I've never tried other biologics"

Fact: Most BCBS policies require documented failure or contraindication to preferred formulary agents before approving Stelara. This typically includes TNF inhibitors like Humira or conventional therapies like methotrexate, depending on your diagnosis.

Myth 3: "All Blue Cross Blue Shield plans have the same Stelara coverage"

Fact: The 36 independent Blue plans maintain separate formularies and PA criteria. BCBS Virginia (Anthem) has specific requirements that differ from Blue Cross Blue Shield of Texas or other states. Always verify your specific plan's requirements.

Myth 4: "TB screening is optional for Stelara approval"

Fact: Tuberculosis screening documentation is mandatory for all biologic approvals, including Stelara. BCBS requires negative TB test results (tuberculin skin test or IGRA) within 12 months of treatment initiation, plus baseline chest X-ray documentation.

Myth 5: "If denied, I have to wait months to appeal"

Fact: Virginia law provides expedited external review within 72 hours for urgent medical situations. The State Corporation Commission Bureau of Insurance offers both standard (45-day) and expedited appeals processes, with no cost to patients.

Myth 6: "Specialty pharmacies automatically get better approval rates"

Fact: While specialty pharmacies often have dedicated PA teams, approval depends on meeting clinical criteria regardless of the pharmacy. Counterforce Health helps patients and providers navigate these requirements by analyzing denial letters and crafting targeted appeals based on each plan's specific policies.

Myth 7: "Generic alternatives are always required first"

Fact: Stelara (ustekinumab) is a biologic without generic equivalents. However, BCBS may require trials of other biologics or conventional therapies before approving Stelara, depending on your diagnosis and plan's step therapy protocol.

Myth 8: "Patient assistance programs affect insurance coverage decisions"

Fact: Manufacturer copay assistance and patient support programs operate independently of insurance coverage decisions. Even with Janssen's patient assistance, you still need insurance approval for coverage.

What Actually Influences Approval

Clinical Documentation Requirements

Disease Severity Scores: BCBS Virginia requires objective measures:

Prior Therapy Documentation: Complete records showing:

  • Specific medications tried, doses, and duration
  • Clinical response or reasons for discontinuation
  • Contraindications or intolerances to preferred agents

Submission Routing and Timing

Correct Channels: Use Anthem's Availity portal or designated fax lines for PA submissions. Incorrect routing delays approval by 5-10 business days.

Complete Forms: Download current PA forms from Anthem's provider portal—outdated forms result in automatic rejections.

Avoid These Critical Mistakes

1. Using Outdated Prior Authorization Forms

Anthem updated PA requirements multiple times in 2024. Always download the most current forms from the provider portal before submission.

2. Incomplete TB Screening Documentation

Submit complete TB screening records including:

  • Laboratory report with negative result
  • Date and method of testing (TST or IGRA)
  • Baseline chest X-ray if history of positive TB test

3. Missing Disease Severity Measurements

Include current, quantitative scores:

  • PASI for psoriasis patients
  • CDAI for Crohn's disease
  • Joint assessment for psoriatic arthritis

4. Inadequate Prior Therapy Documentation

Provide detailed records of:

  • Each medication tried with specific doses
  • Duration of treatment
  • Clinical response or adverse events
  • Clear medical reasons for discontinuation

5. Filing Appeals Too Late

Virginia allows 120 days from final denial to request external review. Missing this deadline eliminates your appeal options.

Quick Action Plan: Three Steps to Take Today

Step 1: Verify Your Coverage Status

Call the member services number on your BCBS Virginia insurance card to confirm:

  • Stelara's formulary tier on your specific plan
  • Current PA requirements and forms needed
  • Your plan's step therapy protocols

Step 2: Gather Required Documentation

Collect these essential documents:

  • Recent TB screening results (within 12 months)
  • Disease severity scores (PASI, CDAI, or joint assessments)
  • Complete prior therapy records
  • Current clinical notes from your specialist

Step 3: Download Current Forms

Visit Anthem's provider portal to download:

  • Most recent PA request forms
  • Clinical criteria checklists
  • Submission guidelines and contact information
From our advocates: We've seen many patients succeed after initial denials by submitting additional TB screening documentation and detailed prior therapy records. The key is addressing every specific requirement mentioned in the denial letter rather than resubmitting the same incomplete information.

Appeals Process in Virginia

Internal Appeals with BCBS Virginia

  • Timeline: 60 days from denial notice
  • Method: Submit via member portal or written request
  • Required: Original denial letter, additional clinical documentation
  • Decision: 30 days for standard, 72 hours for expedited

External Review through Virginia SCC

Virginia's State Corporation Commission Bureau of Insurance provides independent review:

Standard External Review:

  • Timeline: 120 days from final internal denial to file
  • Process: Submit Form 216-A with supporting documents
  • Decision: 45 days from acceptance
  • Cost: Free to patients

Expedited External Review:

  • Timeline: 72 hours for urgent medical necessity
  • Eligibility: Doctor certification that delay could harm health
  • Decision: Final and binding on insurer

Contact Virginia Bureau of Insurance

  • Phone: (877) 310-6560
  • Services: Free guidance on appeal process
  • Forms: Form 216-A (External Review Request)
  • Support: Managed Care Ombudsman assistance

Resources and Support

Official Virginia Resources

BCBS Virginia Contacts

  • Member Services: Number on your insurance card
  • Provider News Portal: Current PA forms and requirements
  • Pharmacy Help Desk: For formulary and PA questions

Patient Support Programs

  • Janssen CarePath: Manufacturer support program for Stelara patients
  • Patient Access Network Foundation: Copay assistance for eligible patients
  • Counterforce Health: Specialized assistance with insurance denials and appeals

When patients face Stelara coverage challenges, Counterforce Health analyzes denial letters against specific payer policies and helps craft evidence-based appeals that address each plan's unique requirements. This targeted approach significantly improves approval rates by ensuring all clinical criteria are properly documented and presented.

FAQ

Q: How long does BCBS Virginia PA take for Stelara? A: Standard PA decisions are made within 5-15 business days. Expedited requests (with urgent medical necessity) receive decisions within 72 hours.

Q: What if Stelara is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives have failed or are contraindicated.

Q: Can I request expedited appeal if my condition is worsening? A: Yes, if your physician certifies that waiting for standard review could harm your health. Submit expedited appeal request with clinical documentation.

Q: Does step therapy apply if I've failed biologics in other states? A: Yes, document prior therapy failures regardless of where treatment occurred. Include complete medical records and provider notes.

Q: What happens if external review upholds the denial? A: The decision is final and binding. Consider consulting an attorney if you suspect policy violations or exploring alternative coverage options.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific BCBS Virginia plan and consult healthcare providers for medical decisions. For personalized assistance with complex cases, consider consulting insurance advocacy services or legal counsel.

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