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Does Affinity Health Plan Cover Stelara

Explore Affinity Health Plan's Stelara coverage, reasons for denial, tips for approval, costs without insurance, and FAQs in our comprehensive guide.

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Coverage for Stelara

Affinity Health Plan may cover Stelara for treating certain chronic conditions such as moderate to severe plaque psoriasis and psoriatic arthritis.

Coverage depends on the member's specific plan benefits, as well as upon meeting medical necessity criteria determined by policy guidelines.

Basic Rules and Criteria

Pre-authorization is typically required, ensuring that the treatment is deemed necessary by a healthcare provider.

Eligibility usually requires documented trials of alternative therapies that were ineffective, inappropriate, or caused adverse effects.

Physician furnishing treatment must provide a detailed medical history and appropriate documentation supporting the need for Stelara.

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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.

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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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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 Stelara Coverage with Affinity Health Plan

Begin with Reviewing Your Insurance Benefits

Log in to your Affinity Health Plan member portal and access your policy documents to understand your coverage specifics.

Locate the section regarding prescription drug coverage to see if biologics like Stelara are included.

Contact Affinity Health Plan Customer Service

Call the customer service number found on your insurance card to confirm Stelara's coverage status.

Inquire about any prerequisites or documentation needed for coverage approval, such as prior authorization requirements.

Consult Your Healthcare Provider

Discuss starting Stelara with your healthcare provider to ensure it’s medically necessary and appropriate for your condition.

Request your provider to prepare and submit any required documentation, like a Letter of Medical Necessity or a prior authorization request, to Affinity Health Plan.

Prepare and Submit Necessary Documentation

Compile all necessary documentation as advised by your healthcare provider and insurance representative.

Ensure your provider submits the prior authorization request to Affinity Health Plan. Follow up with both your provider and insurance to verify submission.

Verify Authorization and Obtain Stelara

Contact Affinity Health Plan after submission to confirm receipt and processing of your authorization request.

Once approved, coordinate with your pharmacy to fill the prescription and verify that it will be billed appropriately according to your plan benefits.

Appeal if Necessary

If your coverage is denied, request the specific reason for denial in writing from Affinity Health Plan.

Work with your healthcare provider to gather any additional or supporting information to strengthen your appeal case.

Submit a formal appeal to Affinity Health Plan and follow up regularly to track the status of your appeal.

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FAQs

Does Affinity Health Plan Cover Stelara

Explore Affinity Health Plan's Stelara coverage, reasons for denial, tips for approval, costs without insurance, and FAQs in our comprehensive guide.

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Is Stelara Covered by Affinity Health Plan

Coverage for Stelara

Affinity Health Plan may cover Stelara for treating certain chronic conditions such as moderate to severe plaque psoriasis and psoriatic arthritis.

Coverage depends on the member's specific plan benefits, as well as upon meeting medical necessity criteria determined by policy guidelines.

Basic Rules and Criteria

Pre-authorization is typically required, ensuring that the treatment is deemed necessary by a healthcare provider.

Eligibility usually requires documented trials of alternative therapies that were ineffective, inappropriate, or caused adverse effects.

Physician furnishing treatment must provide a detailed medical history and appropriate documentation supporting the need for Stelara.

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Affinity Health Plan's Approved Criteria for Stelara Coverage

Eligibility for Coverage

Applicants must have an active Affinity Health Plan membership to be eligible for Stelara coverage.

Stelara is covered for patients with specific covered conditions where other treatment options have been inadequate.

Crohn's Disease Criteria

Candidates must be adults aged 18 or older diagnosed with moderate-to-severe Crohn's disease.

There must be documentation of an inadequate response, intolerance, or contraindication to conventional Crohn's disease therapies, including corticosteroids or immunomodulators.

The treatment plan should include Stelara as either monotherapy or in combination with other appropriate therapies.

Psoriatic Arthritis Criteria

Applicants must be 18 or older with active psoriatic arthritis.

Documented failure or intolerance to at least one disease-modifying antirheumatic drug (DMARD) or targeted therapy should be present.

Stelara may be prescribed as part of a comprehensive treatment plan that includes other therapeutic measures as appropriate.

Plaque Psoriasis Criteria

Candidates should be 18 or older, diagnosed with moderate-to-severe plaque psoriasis, and plaque involvement affecting a significant percentage of body surface area, or cases involving sensitive areas such as face, hands, or feet.

Previous treatment attempts with phototherapy or traditional systemic therapies have been ineffective, intolerable, or contraindicated.

Stelara should be part of a larger treatment regimen tailored to the patient's specific medical needs.

Specialist Prescription Requirement

Coverage of Stelara requires a prescription from a medical professional specializing in the treatment of the specific condition (e.g., dermatologist, rheumatologist).

The prescribing specialist must provide detailed medical records documenting the diagnosis and previous treatment attempts.

Continued Coverage and Assessment

Continued approval for Stelara requires evidence of clinical benefit and patient adherence to the prescribed regimen.

Periodic assessments by the prescribing specialist are necessary to evaluate the ongoing efficacy and continued medical necessity of Stelara therapy.

Why Affinity Health Plan Might Deny Stelara Coverage

Situations Where Affinity Health Plan Might Deny Stelara Coverage

**Diagnosis Not Aligned**: If the patient's diagnosis does not match the specific FDA-approved indications for Stelara, such as moderate to severe plaque psoriasis, Crohn's disease, or ulcerative colitis.

**Lack of Prior Authorization**: If there is no prior authorization obtained from Affinity Health Plan before the administration of Stelara, coverage might be denied.

**Non-Formulary Drug**: If Stelara is not listed on the preferred formulary, the plan might not provide coverage unless a formulary exception is granted.

**Failure of Step Therapy**: Situations where step therapy requirements are not met, meaning other required medications haven’t been tried first, as specified by the plan.

**Inadequate Documentation**: Coverage may be denied if there is insufficient medical documentation to support the need for Stelara based on clinical guidelines.

**Off-label Use**: Administering Stelara for conditions not approved by regulatory agencies without appropriate evidence or necessity as determined by Affinity Health Plan.

**Out-of-Network Providers**: If Stelara is prescribed or administered by providers outside of Affinity Health Plan's network without prior approval.

**Policy Exclusions**: Coverage might be denied if the policy specifically excludes biologic drugs under certain plans or coverage options.

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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 Affinity Health Plan

Begin with Reviewing Your Insurance Benefits

Log in to your Affinity Health Plan member portal and access your policy documents to understand your coverage specifics.

Locate the section regarding prescription drug coverage to see if biologics like Stelara are included.

Contact Affinity Health Plan Customer Service

Call the customer service number found on your insurance card to confirm Stelara's coverage status.

Inquire about any prerequisites or documentation needed for coverage approval, such as prior authorization requirements.

Consult Your Healthcare Provider

Discuss starting Stelara with your healthcare provider to ensure it’s medically necessary and appropriate for your condition.

Request your provider to prepare and submit any required documentation, like a Letter of Medical Necessity or a prior authorization request, to Affinity Health Plan.

Prepare and Submit Necessary Documentation

Compile all necessary documentation as advised by your healthcare provider and insurance representative.

Ensure your provider submits the prior authorization request to Affinity Health Plan. Follow up with both your provider and insurance to verify submission.

Verify Authorization and Obtain Stelara

Contact Affinity Health Plan after submission to confirm receipt and processing of your authorization request.

Once approved, coordinate with your pharmacy to fill the prescription and verify that it will be billed appropriately according to your plan benefits.

Appeal if Necessary

If your coverage is denied, request the specific reason for denial in writing from Affinity Health Plan.

Work with your healthcare provider to gather any additional or supporting information to strengthen your appeal case.

Submit a formal appeal to Affinity Health Plan and follow up regularly to track the status of your appeal.

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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 Affinity Health Plan Cover Stelara

Explore Affinity Health Plan's Stelara coverage, reasons for denial, tips for approval, costs without insurance, and FAQs in our comprehensive guide.

Achieve Your Goals Faster with Curex