Does Affinity Health Plan Cover Humira

Explore how Affinity Health Plan handles Humira coverage, reasons for denial, coverage tips, cost without insurance, and frequently asked questions.
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Overview of Affinity Health Plan Coverage for Humira

 

  • Affinity Health Plan typically covers Humira for conditions such as rheumatoid arthritis, Crohn's disease, psoriasis, and other inflammatory autoimmune diseases.
  •  

  • Coverage is subject to meeting specific medical necessity criteria, which often involve prior authorization from a healthcare provider.

 

Criteria for Coverage

 

  • Patients might need to provide documentation of previous treatments that were ineffective or contraindicated.
  •  

  • Approval often requires a diagnosis confirmed by a specialist in the relevant field, such as a rheumatologist or gastroenterologist.

 

Basic Rules for Obtaining Coverage

 

  • Enrollees should consult with their healthcare provider to ensure all necessary paperwork and justifications are submitted.
  •  

  • Frequent reevaluation by a healthcare provider may be required to continue coverage of Humira under the plan.

 

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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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Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

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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 Humira Coverage with Affinity Health Plan

 

Start with Affinity Health Plan Enrollment

 

  • Contact Affinity Health Plan to verify if they provide coverage for Humira. Ask specifically about prescription drug coverage and what plans include such benefits.
  •  

  • Gather necessary personal and medical information for the application process, such as social security number, medical history, and any other required documentation.

 

Review Coverage Options

 

  • Examine the different health plans offered by Affinity to find the one that includes comprehensive prescription benefits.
  •  

  • Pay special attention to the formulary or drug list to confirm Humira is covered under the plan of interest.

 

Consult with a Healthcare Provider

 

  • Speak with your healthcare provider to confirm that Humira is the appropriate medication for your condition and necessary for treatment.
  •  

  • Obtain a written prescription or necessary medical documentation that supports the need for Humira as a treatment.

 

Submit a Prior Authorization Request

 

  • If required, complete and submit a prior authorization form through your healthcare provider to Affinity Health Plan for approval to cover Humira.
  •  

  • Provide any necessary medical records or additional documentation that may be requested to support the authorization request.

 

Verify Coverage and Costs

 

  • After receiving approval, confirm the coverage details of Humira under your plan, including any copayment, coinsurance, or deductible amounts you are responsible for.
  •  

  • Contact Affinity Health Plan customer service to clarify any remaining questions regarding the coverage of Humira.

 

Navigate Pharmacy Benefits

 

  • Identify participating pharmacies within Affinity's network where you can fill your Humira prescription.
  •  

  • Work with the chosen pharmacy to process and dispense Humira, using your Affinity Health Plan benefits to cover the costs.

 

Manage Ongoing Coverage

 

  • Maintain regular communication with both Affinity Health Plan and your healthcare provider to ensure continuous coverage and address any changes in your treatment plan.
  •  

  • Periodically review your health plan during open enrollment periods to confirm that your current plan continues to meet your prescription needs for Humira.

 

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FAQs

Does Affinity Health Plan Cover Humira

Explore how Affinity Health Plan handles Humira coverage, reasons for denial, coverage tips, cost without insurance, and frequently asked questions.
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Is Humira Covered by Affinity Health Plan

 

Overview of Affinity Health Plan Coverage for Humira

 

  • Affinity Health Plan typically covers Humira for conditions such as rheumatoid arthritis, Crohn's disease, psoriasis, and other inflammatory autoimmune diseases.
  •  

  • Coverage is subject to meeting specific medical necessity criteria, which often involve prior authorization from a healthcare provider.

 

Criteria for Coverage

 

  • Patients might need to provide documentation of previous treatments that were ineffective or contraindicated.
  •  

  • Approval often requires a diagnosis confirmed by a specialist in the relevant field, such as a rheumatologist or gastroenterologist.

 

Basic Rules for Obtaining Coverage

 

  • Enrollees should consult with their healthcare provider to ensure all necessary paperwork and justifications are submitted.
  •  

  • Frequent reevaluation by a healthcare provider may be required to continue coverage of Humira under the plan.

 

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Affinity Health Plan's Approved Criteria for Humira Coverage

 

Eligibility Criteria for Humira Coverage

 

  • Patient must have a confirmed diagnosis of an inflammatory autoimmune condition, such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, or moderate to severe chronic plaque psoriasis.
  •  

  • Documentation indicating that the patient has previously tried and failed or has contraindications to other conventional therapies, such as NSAIDs, corticosteroids, or disease-modifying antirheumatic drugs (DMARDs).
  •  

  • For pediatric patients, coverage may be approved if there is a diagnosis of juvenile idiopathic arthritis or Crohn's disease and conventional therapies have been inadequate or inappropriate.
  •  

  • Physician attestation that the patient cannot receive live vaccines while on Humira, as it is contraindicated.

 

Continuation of Therapy

 

  • Evidence of clinical benefit from Humira, such as improvement in symptoms, function, or quality of life indicators, as documented by the treating physician.
  •  

  • Compliance with the prescribed Humira treatment plan, confirmed through pharmacy or provider reporting.
  •  

  • Absence of severe adverse reactions or side effects necessitating discontinuation, as determined by the healthcare provider.

 

Documentation Requirements

 

  • Submission of relevant medical records, including treatment history with other medications, diagnostic test results, and any pertinent clinical assessments.
  •  

  • Prescription details such as dosage, frequency, and duration of Humira therapy must be provided by the prescribing physician.
  •  

  • Updated lab reports or imaging studies, if applicable, to support the ongoing need for therapy.

 

Coordination with Specialty Pharmacy

 

  • Affinity Health Plan may require the use of a designated specialty pharmacy for the dispensing of Humira to ensure proper handling and support services.
  •  

  • Patient education on Humira administration, storage, and handling available through the specialty pharmacy network.
  •  

  • Access to nursing support for self-injection training, if necessary, facilitated by the specialty pharmacy.

 

Why Affinity Health Plan Might Deny Humira Coverage

 

Reasons for Denial of Humira Coverage by Affinity Health Plan

 

  • Non-formulary Drug Status: Humira may not be included on the formulary list, which consists of medications approved for coverage based on efficacy and cost-effectiveness.
  •  

  • Lack of Prior Authorization: Coverage may be denied if prior authorization has not been obtained. This involves getting approval from Affinity Health Plan before the medication is prescribed.
  •  

  • Failure to Meet Medical Necessity Criteria: If the prescribed use of Humira does not meet Affinity's defined criteria for medical necessity, it may be denied. This could involve not meeting specific diagnostic codes or documented treatment failure with preferred alternatives.
  •  

  • Off-label Use: The medication may be denied if it's prescribed for an off-label use that is not supported by clinical guidelines or lack sufficient medical justification according to Affinity’s policies.
  •  

  • Lack of Step Therapy Compliance: If a patient has not tried and failed other less expensive therapies as required by step therapy protocols, Humira coverage might be denied.
  •  

  • Non-compliance with Plan Limitations: Exceeding the medication quantity limit or lacking documentation to override these limits may result in denial.
  •  

  • Exclusion for Cosmetic Use: Humira prescribed for conditions considered cosmetic, rather than medically necessary, such as certain skin conditions that do not affect health, may be excluded from coverage.
  •  

  • Existing Coverage or Duplicate Therapy: If another plan already covers the medication or if there is duplication with another prescribed biologic therapy, coverage can be denied.

 

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How Much Does Humira Cost without Insurance?

 

Understanding Humira's Cost

 

  • Humira, a medication used to treat various autoimmune conditions, can be quite expensive without insurance coverage.
  •  

  • The cost for a single 40 mg/0.4 ml pen of Humira is typically priced between $5,000 and $6,000, depending on the pharmacy and location.
  •  

  • Patients often require multiple pens per month, so monthly costs can range from $10,000 to $24,000 or more, depending on dosage and frequency of use.
  •  

  • Pharmaceutical companies may offer financial assistance programs or patient support to help lower these costs for eligible patients.
  •  

  • Discount programs and manufacturer coupons could sometimes reduce the cost for patients who qualify.

 

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

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.

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

Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

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 Humira Coverage with Affinity Health Plan

 

Start with Affinity Health Plan Enrollment

 

  • Contact Affinity Health Plan to verify if they provide coverage for Humira. Ask specifically about prescription drug coverage and what plans include such benefits.
  •  

  • Gather necessary personal and medical information for the application process, such as social security number, medical history, and any other required documentation.

 

Review Coverage Options

 

  • Examine the different health plans offered by Affinity to find the one that includes comprehensive prescription benefits.
  •  

  • Pay special attention to the formulary or drug list to confirm Humira is covered under the plan of interest.

 

Consult with a Healthcare Provider

 

  • Speak with your healthcare provider to confirm that Humira is the appropriate medication for your condition and necessary for treatment.
  •  

  • Obtain a written prescription or necessary medical documentation that supports the need for Humira as a treatment.

 

Submit a Prior Authorization Request

 

  • If required, complete and submit a prior authorization form through your healthcare provider to Affinity Health Plan for approval to cover Humira.
  •  

  • Provide any necessary medical records or additional documentation that may be requested to support the authorization request.

 

Verify Coverage and Costs

 

  • After receiving approval, confirm the coverage details of Humira under your plan, including any copayment, coinsurance, or deductible amounts you are responsible for.
  •  

  • Contact Affinity Health Plan customer service to clarify any remaining questions regarding the coverage of Humira.

 

Navigate Pharmacy Benefits

 

  • Identify participating pharmacies within Affinity's network where you can fill your Humira prescription.
  •  

  • Work with the chosen pharmacy to process and dispense Humira, using your Affinity Health Plan benefits to cover the costs.

 

Manage Ongoing Coverage

 

  • Maintain regular communication with both Affinity Health Plan and your healthcare provider to ensure continuous coverage and address any changes in your treatment plan.
  •  

  • Periodically review your health plan during open enrollment periods to confirm that your current plan continues to meet your prescription needs for Humira.

 

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Humira FAQ

What are the side effects of Humira?

 

Common Side Effects of Humira

 

  • Injection site reactions: redness, itching, or swelling.
  • Upper respiratory infections: sinus congestion and sore throat.
  • Headaches and nausea.

 

Serious Side Effects

 

  • Severe allergic reactions: difficulty breathing, chest pain, or swelling of the face.
  • Risk of infections: tuberculosis, fungal, or viral infections.
  • Blood disorders: unusual bruising or bleeding, pale skin.
  • Heart problems: shortness of breath, swelling of ankles/feet.

 

Long-term Considerations

 

  • Increased risk of certain cancers, particularly lymphomas.
  • Possible liver issues: jaundice or dark urine.

 

How does Humira work for rheumatoid arthritis?

 

How Humira Works

 

  • Humira is a TNF inhibitor. TNF, or tumor necrosis factor, is a substance in the body that causes inflammation.
  •  

  • By blocking TNF, Humira helps reduce inflammation and slow disease progression in rheumatoid arthritis patients.
  •  

  • It targets the underlying cause of inflammation instead of just managing symptoms, providing longer-term relief from discomfort and joint damage.

 

Administration and Effects

 

  • Administered as a subcutaneous injection, typically every two weeks.
  •  

  • Many patients start experiencing relief within a few weeks, though full benefits may take longer.
  •  

  • Consistent use can lead to improved mobility, reduced pain, and decreased swelling, assisting in daily activities.

How often do you take Humira injections?

 

Frequency of Humira Injections

 

  • **Initial Dose**: Typically, patients start with a loading dose. For example, in rheumatoid arthritis, a patient may begin with 160 mg on day 1, followed by 80 mg on day 15.
  •  

  • **Maintenance Dose**: After the initial period, the standard maintenance dose is usually 40 mg every other week. However, some patients may benefit from a weekly dose, depending on the condition and doctor's advice.
  •  

  • **Adjustments**: Dosage frequency may be adjusted based on response and tolerability, making healthcare provider consultation crucial.

 

Consulting Your Physician

 

  • Due to the varying nature of autoimmune conditions, always consult your healthcare professional to determine the appropriate regimen for your specific situation.

 

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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 (the active ingredient in Wegovy®* and Ozempic®*). 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 if I sign up?

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.

How much does treatment cost?

Semaglutide Injections:

Prices for semaglutide start at only $149 per month for weekly doses of 0.25mg and 0.5mg. You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 1mg, 1.7mg and 2.4mg of semaglutide for an additional $50 per month for each plan.

Tirzepatide Injections:

Prices for tirzepatide start at only $249 per month for weekly doses of 2.5mg and 5mg of tirzepatide.You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 7.5mg, 10mg and 12.5mg of tirzepatide for an additional $100 per month for each plan.

Semaglutide Tablets:

Prices for semaglutide tablets start at only $149 per month for daily doses of 2mg. You can cancel anytime. Some people experience weight loss at this dose and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 4mg and 8mg of semaglutide daily for an additional $50 per month for each plan.

Tirzepatide Tablets:

Prices for tirzepatide start at only $199 per month for daily dosees of 3mg of tirzepatide. You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 6mg and 12 mg of tirzepatide daily for an additional $100 per month for each plan.

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. While we don’t prescribe Ozempic®* or Wegovy®* directly, we may prescribe treatments containing the same active ingredient. 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.

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