By Counterforce Health Team in Stelara (ustekinumab) —

Renewing Stelara (Ustekinumab) Coverage with Cigna in New York: Timeline, Forms, and Appeal Options

Answer Box: Renewing Stelara Coverage with Cigna in New York

Cigna requires prior authorization renewal for Stelara every 6 months (initial) to 1 year (continuation). Start renewal 30-45 days before expiration. Submit updated clinical documentation showing continued response via PASI scores, CDAI, or Mayo scores through your prescriber. If coverage lapses, request bridge therapy through Accredo. For denials, file internal appeals within 180 days, then external appeals through New York DFS within 4 months.

Table of Contents

  1. Understanding Renewal Triggers
  2. Evidence Updates Required
  3. Building Your Renewal Packet
  4. Critical Timelines
  5. When Coverage Lapses
  6. Navigating Annual Changes
  7. Personal Progress Tracker
  8. Appeals Process in New York
  9. FAQ

Understanding Renewal Triggers

Cigna's renewal requirements for Stelara depend on your treatment phase and formulation. Here's when you need to start preparing:

Approval Duration by Formulation:

  • IV Stelara: 30-day approvals (one infusion cycle)
  • Subcutaneous (initial therapy): 6-month approvals
  • Subcutaneous (continuation): 1-year approvals after demonstrating 6+ months of benefit
Note: These timelines apply to Cigna's current prior authorization policies and may vary by specific plan design.

Signs You Should Start Renewal Early:

  • Your approval expires within 60 days
  • Recent lab changes or side effects that need documentation
  • Switching from IV to subcutaneous maintenance
  • Plan formulary changes announced for the upcoming year
  • Previous renewal took longer than expected

Evidence Updates Required

Cigna requires objective evidence of continued therapeutic benefit. The specific measures depend on your condition:

Response Monitoring by Condition

Condition Primary Measure Renewal Criteria Frequency
Psoriasis PASI Score PASI 75 or 90 improvement Every 6-12 months
Crohn's Disease CDAI <150 (remission) or >100-point drop Every 6-12 months
Ulcerative Colitis Mayo Score ≥3-point, ≥30% reduction + bleeding improvement Every 6-12 months

Required Lab Updates:

Documentation of Adherence

Your prescriber must document:

  • Injection compliance (subcutaneous patients)
  • Infusion attendance (IV patients)
  • Any missed doses and reasons
  • Side effects or tolerability issues

Building Your Renewal Packet

Must-Include Documents:

  1. Updated Letter of Medical Necessity from your prescriber
  2. Current disease activity scores (PASI, CDAI, or Mayo)
  3. Recent lab results (within 3-6 months)
  4. Treatment timeline showing duration on Stelara
  5. Prior therapy documentation (if not previously submitted)

Medical Necessity Letter Checklist

Your prescriber should include:

  • Current diagnosis with ICD-10 codes
  • Objective disease activity measurements
  • Previous treatment failures or contraindications
  • Clinical response to Stelara with specific metrics
  • Planned monitoring schedule
  • Citations to relevant treatment guidelines
Clinician Corner: Reference the FDA-approved Stelara prescribing information and specialty society guidelines (AAD for psoriasis, ACG for IBD) to strengthen medical necessity arguments.

Critical Timelines

Renewal Submission Timeline:

  • 45 days before expiration: Start gathering documentation
  • 30 days before: Submit renewal request
  • 15 days before: Follow up if no response
  • At expiration: Request bridge therapy if needed

Cigna Decision Windows:

  • Standard prior authorization: 15 business days
  • Expedited requests (urgent): 72 hours
  • Appeals (internal): 30 days for standard, 72 hours for expedited

Important: 2025 Formulary Changes

Beginning March 2025, Cigna is transitioning patients from branded Stelara to Yesintek biosimilar at $0 out-of-pocket cost through Accredo. This may affect your renewal process and require updated prior authorization.

When Coverage Lapses

If your Stelara approval expires before renewal is complete:

Immediate Steps:

  1. Contact Accredo (Cigna's specialty pharmacy) immediately
  2. Request bridge therapy - typically 30-day emergency supply
  3. Have prescriber submit urgent PA with clinical justification
  4. Document the lapse for potential appeal

Bridge Therapy Options:

Tip: New York regulations require insurers to provide transition supplies when coverage changes mid-year. Reference this right when requesting bridge therapy.

What to Re-verify Annually:

  • Formulary tier placement for Stelara
  • Prior authorization requirements
  • Preferred specialty pharmacy changes
  • Copay assistance program eligibility
  • Step therapy requirements

2025 Specific Changes for Cigna:

  • Addition of Yesintek biosimilar to formulary
  • Potential tier changes for branded Stelara
  • Updated prior authorization forms
  • Modified quantity limits or dosing restrictions

Review Cigna's 2025 prescription drug list changes to understand how these affect your coverage.

Personal Progress Tracker

Use this template to log your renewal progress:

Current Approval Details:

  • Approval expiration date: ___________
  • Last PASI/CDAI/Mayo score: ___________
  • Most recent labs date: ___________
  • Prescriber contact: ___________

Renewal Checklist:

  • Renewal packet submitted (date: _______)
  • Cigna confirmation received
  • Decision received (date: _______)
  • New approval dates: ___________

Appeals Process in New York

If your renewal is denied, New York provides strong appeal rights:

Internal Appeals with Cigna

  • Timeline: 180 days from denial
  • Process: Submit through Cigna member portal or mail
  • Required: Denial letter, medical records, prescriber letter
  • Decision: 30 days (72 hours if expedited)

External Appeals through New York DFS

  • Eligibility: After internal appeal denial
  • Timeline: 4 months from final internal denial
  • Cost: $25 maximum (waived for Medicaid/financial hardship)
  • Decision: Binding on Cigna

Key Resources:

From Our Advocates: "We've seen Stelara denials overturned when providers included specific disease activity scores and referenced successful cases from the DFS database. The key is showing objective clinical need and citing precedent from similar approved cases."

When preparing appeals, use Counterforce Health's platform to generate evidence-backed rebuttals that align with Cigna's specific denial reasons and New York's appeal requirements.

FAQ

How long does Cigna prior authorization take in New York? Standard requests: 15 business days. Expedited requests for urgent needs: 72 hours. Submit renewals 30 days early to avoid lapses.

What if Stelara becomes non-formulary? Request a formulary exception with clinical justification. Cigna must provide 30-day notice of formulary changes and offer exception processes.

Can I get expedited appeals in New York? Yes. New York allows expedited external appeals with decisions in 72 hours (24 hours for urgent drug denials) when health is at serious risk.

Does step therapy apply if I'm already established on Stelara? Generally no for renewals, but new prior authorization may trigger step therapy requirements. Document previous failures clearly.

How do I access the Yesintek biosimilar through Cigna? Contact Accredo at the number on your member card. Most patients pay $0 out-of-pocket through the manufacturer copay program.

What counts as medical necessity for Stelara renewal? Objective improvement in disease activity scores (PASI, CDAI, Mayo), stable or improving lab values, and absence of serious adverse events.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For personalized assistance with insurance appeals and prior authorization, Counterforce Health helps patients and clinicians turn denials into successful, evidence-backed appeals.

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