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Mychoice Page | STELARA® (ustekinumab)

You and your doctor have decided that

STELARA® IS RIGHT FOR YOU

If your doctor has prescribed STELARA® (ustekinumab) for you, and you have learned that your health insurance plan will not help pay for your treatment with STELARA®, know that you can challenge that decision. You do not have to go through this process alone. Your healthcare team may be able to help you.

If your coverage for STELARA® has changed, know that there are steps you can consider taking:

Speak Up Icon

Speak Up

Talk to your healthcare team about getting STELARA®

Take Action Icon

Take Action

Challenge your health insurance plan's decision

Get Support Icon

Get Support

Learn about resources to support you

DOWNLOAD A HELPFUL RESOURCE YOU CAN USE TO TRACK YOUR PROGRESS.

SPEAK UP

Talk to People and Organizations That Can Help You

Below are questions you can consider asking to help you get started.

  • Am I being prescribed a different medication?
  • If you are being asked to switch to a biosimilar: What is a biosimilar?
  • Can you explain the risks and benefits of the different medication I am being prescribed?
  • How can I continue my treatment with STELARA®?
  • Can you help me challenge my health insurance plan’s coverage decision?
  • Why am I not receiving STELARA®, the medication my doctor prescribed?
  • What are the side effects of the new medication I am receiving?
  • Is there any patient support available?
  • Why is my treatment with STELARA® not covered?
  • Why has my health insurance coverage for STELARA® changed?
  • What is the process for challenging this coverage decision?
  • What steps do I need to take to get STELARA®?

DOWNLOAD SOME QUESTIONS YOU CAN ASK YOUR HEALTHCARE TEAM HERE.

TAKE ACTION

Ask Your Health Insurance Plan to Reconsider Their Coverage Decision

You can consider challenging your health insurance plan's decision. You do not have to go through this process alone because there are organizations and resources that may be able to help you.

One step you can take is writing an exception letter.

  • An exception letter can be used when your health insurance plan doesn’t normally cover STELARA® on their formulary. You or your doctor can ask your health insurance plan to make an exception for you based on your specific situation.
  • Your health insurance plan may provide a form on its website to apply for an exception. The sample letter templates that you can download below may help you better understand the information that may be required.

This letter comes from you or your doctor and is often submitted with documents listed below (if available) to further support your request:

  • Required medical records
  • Letter of medical necessity

Below are downloadable letters of exception templates that you or your doctor can use to request an exception from your health insurance plan. If you are taking STELARA® for the first time, you or your doctor should use the “new patient” templates. If you have been taking STELARA® for some time, you or your doctor should use the “existing patient” templates.

EXCEPTION LETTER TEMPLATE & INSTRUCTIONS

NEW PATIENT TEMPLATE WRITTEN BY YOU

EXISTING PATIENT TEMPLATE WRITTEN BY YOU

NEW PATIENT TEMPLATE WRITTEN BY YOUR DOCTOR

EXISTING PATIENT TEMPLATE WRITTEN BY YOUR DOCTOR

GET SUPPORT

Learn About Resources That May Be Able to Help You

The following resources and organizations may be able to help you find patient support or better understand how to challenge your health insurance plan's decision.

Once you and your doctor have decided STELARA® is right for you

Dedicated Support–Every Step of the Way

Having a positive treatment journey starts with getting the right support. That's why STELARA withMe is here with you for the important steps.

Nurse Navigator*

When you enroll in STELARA withMe, you'll be contacted by a dedicated Nurse Navigator, a registered nurse who's just a phone call away. Your Nurse Navigator is ready to offer support and answer questions about STELARA®.

Prescription & Cost Support

You'll receive support to help you verify your insurance coverage, understand how to fill your prescriptions, and look for options that could make your treatment more affordable.

Treatment Support

Your Nurse Navigator can help provide infusion support and additional self-injection training. They can also offer support to help you stay on track throughout your treatment journey.

*Nurse Navigators do not provide medical advice. Please ask your doctor any questions you might have about your disease and treatment.

STELARA withMe is limited to education about STELARA®, its administration, and/or the condition it treats. It is not intended to provide medical advice, replace a treatment plan you receive from your doctor or nurse, or serve as a reason for you to start or stay on treatment.

Eligibility for program components may vary.

Coverage Rights

https://coveragerights.org

Get helpful information to guide you when you are denied coverage for your treatment. Select your state to learn more about how to appeal your health insurance plan’s decision based on the rules and regulations in your state.

Consumer Assistance Program (CAP)

https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants

Get direct assistance with insurance-related issues for all coverage types, available by phone or e-mail or at walk-in locations, through your state’s CAP.

Centers for Medicare & Medicaid Services (CMS) Coverage Determinations

https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/
CoverageDeterminations-

Understand what coverage determination is and the steps you can take to request one.

Medicare Prescription Drug Coverage Appeals

https://www.medicare.gov/medicare-prescription-drug-coverage-appeals

Learn about the steps you can take if Medicare has denied coverage for your medication, information on requesting an exception and filing an appeal if your exception request is denied, and answers to important frequently asked questions.

Crohn’s and Colitis Foundation

https://www.crohnscolitisfoundation.org/managing-the-cost-of-ibd/what-to-do-if-denied-coverage

If your exception request has been denied, get detailed explanations of common coverage denial reasons and helpful information on how you can appeal.

National Psoriasis Foundation: Paying for Treatment

https://www.psoriasis.org/paying-for-treatment/

Learn about cost support options for treatment and tips on how to navigate health insurance plans to help you choose fair and affordable options.

DOWNLOAD THE LIST OF RESOURCES HERE.

Talk to your healthcare team about next steps for getting STELARA® or visit stelarainfo.com for additional information about resources and support that may be available to you.