Does Cigna cover Stelara (ustekinumab)?

Cigna covers Stelara (ustekinumab) on a prior authorization basis when the patient meets the criteria in Stelara (ustekinumab) – Cigna/Express Scripts PA: PsO, PsA, Crohn's, or UC with ICD-10; Prior trial of preferred biosimilar or anti-TNF.

Why did Cigna deny my Stelara (ustekinumab) claim?

The most common triggers are: Preferred biosimilar not tried; Missing screening labs; Non-specialist prescriber flag. Check the exact reason on your denial letter.

How do I appeal a Cigna denial of Stelara (ustekinumab)?

Cigna/ESI applies biosimilar-first policy aggressively on 2025 formularies — document biosimilar intolerance (injection-site reaction, primary non-response after ≥12 weeks) with objective measures. Peer-to-peer with medical director is often decisive.

What is the appeal deadline for Cigna?

180 days from the date of the denial notice to file an internal appeal. Expedited appeals are decided in 72 hours.

What federal law backs my right to appeal a Cigna Stelara (ustekinumab) denial?

For employer-sponsored (ERISA) plans, the claim procedure rules in 29 CFR § 2560.503-1 require a full and fair review by a different reviewer, access to the criteria used, and a written decision. All non-grandfathered commercial plans additionally owe you internal appeal plus independent external review under 45 CFR § 147.136.

Cigna denied claim appeal

Cigna · updated for 2026 · Verified against Cigna (2026-06-16)

To appeal a Cigna denied claim you have 180 days from the date of denial to file an internal appeal. Send a written appeal that cites the Cigna clinical policy named in the denial letter, includes a letter of medical necessity, and attaches the records that meet each criterion. If urgent, request an expedited review within 72 hours.

Appeal in 4 steps

1Read the Cigna denial letter (EOB) and identify the cited medical policy.
2Request the full clinical policy bulletin from Cigna; ERISA plans must provide it free of charge.
3Gather office notes, imaging, prior therapy history, and a letter of medical necessity from your treating physician.
4Submit the appeal in writing to the address on the denial letter, by certified mail and through mycigna.com if available, within 180 days.

Key facts

Internal appeal window	180 days from denial
External review window	120 days after final internal denial
Expedited appeal	Decision within 72 hours
Appeals address	Submit via the Cigna Customer Appeal Request form (cigna.com/static/www-cigna-com/docs/appeal.pdf) or through myCigna. The plan-specific mailing address is printed on the form and on your denial letter.
Phone	Customer service number on the back of your ID card
Member portal	mycigna.com

Cigna's appeals page directs members to call customer service within 180 calendar days of the initial payment or denial notice. Standard medical-necessity appeals are decided in 30 days; post-service administrative appeals in 60 days.

Primary source: Cigna — official appeals pageCigna: 'call customer service at the telephone number on your ID card within 180 calendar days of the date of the initial payment or denial notice.' Last verified: 2026-06-16.

Draft a Cigna appeal letter in minutes

Upload the denial letter. Get the cited policy identified, the evidence checklist, and a finished appeal letter you can sign.

Draft my appeal letter

Common Cigna denial reasons

Not medically necessary
Prior authorization required
Step therapy not completed
Out of network
Service not covered

Evidence checklist

✓Denial letter (EOB)
✓Member ID and claim number
✓Treating physician letter of medical necessity
✓Office notes from the last 12 months
✓Imaging or lab reports
✓Cigna clinical policy bulletin (cited in denial)
✓Prior therapy history
✓Specialty guideline citation

Drug-specific Cigna appeals

Verified prior-authorization criteria and override strategy per medication.

Cigna appeal by denial reason

Verified policy basis and override strategy for each common reason Cigna cites.

FAQ

How long do I have to appeal a Cigna denial?+

180 days from the date of the denial to file an internal appeal. Expedited (urgent) appeals must be decided within 72 hours.

Where do I send a Cigna appeal?+

Use the address on your denial letter (the EOB). Addresses vary by plan and region; the denial letter is authoritative.

Can I appeal a Cigna denial without a lawyer?+

Yes. Most internal appeals are filed by the member or the treating physician. The appeal should cite the insurer's clinical policy and include a letter of medical necessity.

What happens after the internal appeal?+

If the final internal appeal is denied, you have 120 days to request external review by an Independent Review Organization. External review is binding on the insurer.

Other insurers

Keep reading

Appeal process

Common denial reasons

Guides you may need

Not legal or medical advice. This page is a self-help resource. You make your own decisions. Strip personal identifiers (name, date of birth, address, member ID) from any document before uploading or sharing. The information here summarizes commonly-published payer policies and federal rules; confirm against your specific plan document and the current denial letter before acting.