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Does Aetna Cover Stelara

Explore Aetna's coverage for Stelara, reasons for denial, coverage options, costs without insurance, and FAQs in our comprehensive guide.

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Does Aetna Cover Stelara?

Aetna may cover Stelara, subject to the plan specifics and medical necessity. Coverage is typically offered for conditions like moderate to severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis in patients meeting specific criteria.

Medical necessity often requires documentation from a healthcare provider detailing the patient's diagnosis and previous treatments tried and failed. Other treatments may need to have been attempted before approval for Stelara.

Preauthorization is usually required for coverage. This involves submitting a request to Aetna with all necessary documentation, ensuring that the treatment fits within Aetna’s clinical guidelines.

Covered dosage and frequency may vary, so it's crucial to check individual policy details. Some plans may have preferred pricing arrangements with certain pharmacies or require the use of specialty pharmacies.

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Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

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At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

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Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Stelara Coverage with Aetna

Understand Aetna's Insurance Policy

Carefully review Aetna's insurance policy to grasp the drug coverage specifics, including any restrictions or requirements for biologic medications like Stelara.

Examine the formulary on Aetna's website to determine if Stelara is included and under what conditions it is covered.

Consult with Your Healthcare Provider

Discuss with your healthcare provider the medical necessity for Stelara in your treatment plan.

Ensure your provider has comprehensive documentation, including your diagnosis, history of previous treatments, and the rationale for prescribing Stelara.

Contact Aetna's Customer Service

Call Aetna's customer service to confirm Stelara's coverage under your specific plan. Ask about any prerequisites or documentation needed for coverage approval.

Note any special requirements such as prior authorization, step therapy, or quantity limits applicable to Stelara.

Submit a Prior Authorization Request

Work with your healthcare provider to prepare a detailed prior authorization request, including all necessary medical documentation and justification.

Submit the request through the appropriate Aetna channels, ensuring all forms are completed accurately to avoid processing delays.

Follow Up on the Authorization Process

Regularly check the status of your prior authorization request through Aetna's customer service or online portal.

Be prepared to provide additional information if Aetna requests it during the review process.

Appeal if Necessary

If Aetna denies coverage for Stelara, obtain detailed reasoning for the denial from their communication.

Work with your healthcare provider to gather additional supporting documentation and submit an appeal as per Aetna's guidelines.

Explore Assistance Programs

Research patient assistance programs offered by Stelara's manufacturer, which may provide financial support or resources to help reduce costs.

Discuss additional discounts or support options with your pharmacy or healthcare provider.

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FAQs

Does Aetna Cover Stelara

Explore Aetna's coverage for Stelara, reasons for denial, coverage options, costs without insurance, and FAQs in our comprehensive guide.

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Is Stelara Covered by Aetna

Does Aetna Cover Stelara?

Aetna may cover Stelara, subject to the plan specifics and medical necessity. Coverage is typically offered for conditions like moderate to severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis in patients meeting specific criteria.

Medical necessity often requires documentation from a healthcare provider detailing the patient's diagnosis and previous treatments tried and failed. Other treatments may need to have been attempted before approval for Stelara.

Preauthorization is usually required for coverage. This involves submitting a request to Aetna with all necessary documentation, ensuring that the treatment fits within Aetna’s clinical guidelines.

Covered dosage and frequency may vary, so it's crucial to check individual policy details. Some plans may have preferred pricing arrangements with certain pharmacies or require the use of specialty pharmacies.

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Aetna's Approved Criteria for Stelara Coverage

Criteria for Coverage of Stelara under Aetna Insurance

**Diagnosis of Crohn's Disease**:
- The member must have a documented diagnosis of moderate to severe Crohn's disease.
- There should be an inadequate response, intolerance, or contraindication to prior therapy including steroids, immunomodulators, or other biologics.

**Diagnosis of Ulcerative Colitis**:
- The member must have a documented diagnosis of moderate to severe ulcerative colitis.
- Failure, intolerance, or contraindication must be shown for conventional therapy like aminosalicylates, corticosteroids, or immunosuppressants.

**Diagnosis of Psoriatic Arthritis**:
- The member must have active psoriatic arthritis and must have tried and had an inadequate response to at least one other disease-modifying antirheumatic drug (DMARD).

**Diagnosis of Plaque Psoriasis**:
- The member must have chronic moderate to severe plaque psoriasis (affecting more than 5% of body surface area or affecting crucial body parts).
- There should be an inadequate response, intolerance, or contraindication to phototherapy or systemic therapy.

**Prescribing Requirements**:
- Stelara must be prescribed by or in consultation with a dermatologist, gastroenterologist, or rheumatologist.

**Age Specifications**:
- For the treatment of Crohn's disease, the member must be 18 years of age or older.
- For the treatment of plaque psoriasis, the member must be 12 years of age or older.

**Dosing and Administration**:
- Stelara must be administered according to FDA-approved labeling.
- Continuation of therapy requires documented medical benefit from treatment.

Why Aetna Might Deny Stelara Coverage

Aetna Denial Criteria for Stelara Coverage

Stelara is not covered for individuals using it for conditions that are not approved by the FDA. Off-label use does not qualify for coverage under Aetna's policy.

Patients who fail to meet Aetna’s medical necessity criteria for Stelara, such as not having a confirmed diagnosis of moderate to severe plaque psoriasis, psoriatic arthritis, Crohn’s disease, or ulcerative colitis, may be denied coverage.

Coverage may be denied if the patient has not tried and failed appropriate conventional therapies as a prerequisite to using Stelara, where applicable according to Aetna’s clinical policy bulletins.

Aetna may deny coverage when there is no documentation of adequate response to prior biologic therapies, which can be a requirement for Stelara approval.

Requests for Stelara administration in quantities exceeding the FDA-approved dosing schedule, or outside the recommended dosing limits, may not be covered.

Insurance claims for Stelara may be rejected if there is a lack of sufficient medical documentation including lab results, imaging, or specialist consultation notes supporting the Stelara treatment plan.

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How Much Does Stelara Cost without Insurance?

Approximate Cost of Stelara without Insurance

The price of Stelara, a medication used primarily for treating conditions such as psoriasis and Crohn's disease, can vary based on the pharmacy and other location-based factors, but without insurance, it typically costs around $20,000 to $40,000 per year.

Individual dosage needs and treatment plans can affect the total cost, as Stelara injections are spaced differently depending on treatment guidelines for specific conditions.

Pricing can also vary depending on the dosage strength; the standard doses are 45 mg and 90 mg, with the 90 mg dose generally being more expensive.

Patients can sometimes find manufacturer coupons or patient assistance programs that help reduce the cost of Stelara. These programs usually require an application process and eligibility criteria.

Additionally, discount pharmacy programs or third-party coupon providers might offer savings, although these are often limited and may vary in percentage or availability.

Clinical Support

Our team is here to help!

Dr. Neeta Ogden, MD

Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

Dr. Ravi Patel, VP Telemedicine

Jill Hamburg, PA - C

Immunotherapy made simple. We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Kayla Mardaga, NP

How to Get Stelara Coverage with Aetna

Understand Aetna's Insurance Policy

Carefully review Aetna's insurance policy to grasp the drug coverage specifics, including any restrictions or requirements for biologic medications like Stelara.

Examine the formulary on Aetna's website to determine if Stelara is included and under what conditions it is covered.

Consult with Your Healthcare Provider

Discuss with your healthcare provider the medical necessity for Stelara in your treatment plan.

Ensure your provider has comprehensive documentation, including your diagnosis, history of previous treatments, and the rationale for prescribing Stelara.

Contact Aetna's Customer Service

Call Aetna's customer service to confirm Stelara's coverage under your specific plan. Ask about any prerequisites or documentation needed for coverage approval.

Note any special requirements such as prior authorization, step therapy, or quantity limits applicable to Stelara.

Submit a Prior Authorization Request

Work with your healthcare provider to prepare a detailed prior authorization request, including all necessary medical documentation and justification.

Submit the request through the appropriate Aetna channels, ensuring all forms are completed accurately to avoid processing delays.

Follow Up on the Authorization Process

Regularly check the status of your prior authorization request through Aetna's customer service or online portal.

Be prepared to provide additional information if Aetna requests it during the review process.

Appeal if Necessary

If Aetna denies coverage for Stelara, obtain detailed reasoning for the denial from their communication.

Work with your healthcare provider to gather additional supporting documentation and submit an appeal as per Aetna's guidelines.

Explore Assistance Programs

Research patient assistance programs offered by Stelara's manufacturer, which may provide financial support or resources to help reduce costs.

Discuss additional discounts or support options with your pharmacy or healthcare provider.

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Stelara FAQ

What are the common side effects of Stelara?

Common Side Effects of Stelara

**Infections:** Increased susceptibility to infections such as upper respiratory infections and strep throat.
**Headache:** This is a frequently reported side effect among patients who use Stelara.
**Tiredness:** Many individuals may experience fatigue or tiredness while on this medication.
**Redness at Injection Site:** Skin irritation, including redness, itching, or swelling, can occur at the site of injection.
**Nausea:** Some patients report feeling mildly nauseated after taking the medication.

How does Stelara work for psoriasis?

Mechanism of Action

Stelara is a monoclonal antibody that targets interleukin-12 (IL-12) and interleukin-23 (IL-23), which are proteins involved in inflammatory processes associated with psoriasis.

Impact on the Immune System

By inhibiting IL-12 and IL-23, Stelara reduces the activity of specific immune cells (T-cells) that contribute to the inflammation and rapid skin cell production characteristic of psoriasis.

Clinical Efficacy

Many patients experience significant reductions in psoriasis symptoms, including skin clearance, with improvements often visible within weeks after initial treatment.

Administration and Dosage

Stelara is administered via subcutaneous injection, starting with a loading dose followed by maintenance doses every 12 weeks thereafter.

How often do you need Stelara injections?

Stelara Injection Schedule

Initial Doses: After the first dose is administered, a second dose follows four weeks later.

Maintenance Doses: Subsequent injections are given every 12 weeks.

Special Cases: Depending on specific conditions like Crohn's disease, the frequency may vary under a physician's guidance.

Administration: Stelara is typically administered as a subcutaneous injection which can be performed in a healthcare setting or self-administered after proper training.

Consult Your Doctor: Always consult with your healthcare provider to tailor the schedule to your medical needs.

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Initial Dosage

Your initial medication and dosage are carefully determined by doctors, taking into account your unique health profile. This ensures a personalized and safe treatment plan tailored to your specific needs.

Titration

We gradually adjust your dosage to reach the optimal therapeutic level, ensuring maximum effectiveness while minimizing potential side effects.

Additional Treatments

Our providers may also recommend medications such as metformin or supplements such as vitamin B12. We recognize the importance of managing side effects, so your care plan may include medication to alleviate them.

Got questions? We have answers.

Do your plans include prescriptions and medications?

Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you. Our service includes continuous support and regular follow-ups to ensure your treatment stays on track.

Our clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance.

Please note: Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.

What medications do your providers prescribe?

We prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide. Our providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster.

Depending on your treatment goals, other medications such as metformin may also be considered. We recognize the importance of managing side effects, so your care plan might include medication to ease symptoms like nausea. Your well-being is always our top priority!

Please note that compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness. A prescription is necessary. Results may vary from person to person.

Curex and its pharmacy partners do not have any association with Novo Nordisk.

Will I be prescribed semaglutide?

Your health journey is unique, and we tailor our care to match. Any prescriptions, including semaglutide, will be based on the expert assessment of the medical provider matched with you through our platform. You can trust that your treatment plan will be personalized to fit your specific needs. And if semaglutide is not prescribed, we will provide a full refund.

What is compounded medication?

Compounding involves creating customized medications to meet the specific needs of individual patients. For instance, a patient may require a liquid version of a medication that is only available in tablet form. Pharmacies can also compound medications using FDA-approved drugs that are on the FDA’s shortage list.

These compounded medications are made by state-licensed pharmacies that follow both federal and state regulations, including quality standards. However, when compounded in accordance with these laws, these medications are not subject to FDA approval and are not evaluated for safety or effectiveness.

Is compounded medication the same as generic medication?

Compounded medications differ from generic drugs. Generics require FDA approval by demonstrating bio-equivalence to the brand-name drug. In contrast, compounded medications are not FDA-approved. They are made based on a personalized prescription that may not be commercially available elsewhere or when a drug appears on the FDA’s shortage list. Compounding pharmacies must have the proper licensed facilities and comply with state and federal regulations before dispensing these medications.

Is insurance required?

No, Curex doesn’t require insurance. We offer clear and simple pricing, along with affordable medication options, making it easy and accessible to take care of your health.

Can I pay with an FSA or HSA card?

Yes! You can pay with your HSA or FSA card.

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. We don’t prescribe Ozempic®* or Wegovy®.* We may prescribe treatments containing compounded semaglutide or tirzepatide. These medications are specially compounded for you by a licensed pharmacy to meet your specific needs.

Are video visits with a provider required?

Our providers will review your information 100% online. Depending on where you live and the specifics of your medical history, our providers may require you to have a video visit or asynchronous visit via text message. If prescribed, you’ll get unlimited online access to message your provider as needed for follow-ups, adjustments, and answers to your questions.

What states do you serve?

Currently, we do not serve Arkansas, Connecticut, and New Mexico. However, we are always working to expand our reach, so stay in touch with us at hi@getcurex.com.

Does Aetna Cover Stelara

Explore Aetna's coverage for Stelara, reasons for denial, coverage options, costs without insurance, and FAQs in our comprehensive guide.

Achieve Your Goals Faster with Curex