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Does Amerigroup Cover Stelara

Explore Amerigroup's Stelara coverage, reasons for denial, tips to secure coverage, costs without insurance, and frequently asked questions.

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Does Amerigroup Cover Stelara?

Amerigroup typically covers Stelara for specific conditions such as moderate to severe plaque psoriasis, active psoriatic arthritis, and moderate to severe Crohn's disease or ulcerative colitis. Prior authorization is commonly required.

Coverage criteria often include a confirmed diagnosis by a healthcare professional, insufficient response or intolerance to other treatments, and medical necessity as documented by your healthcare provider.

Patients might need to provide documented history of their condition and failed attempts with previous medications.

It's essential to consult your specific plan details or contact an Amerigroup representative for precise information, as coverage terms and requirements might vary based on your plan and state regulations.

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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 Stelara Coverage with Amerigroup

Start by Reviewing Your Amerigroup Plan

Access your Amerigroup member portal to review your specific plan details and determine the level of coverage offered for medications, including biologics like Stelara.

Check the formulary list provided by Amerigroup to confirm that Stelara is covered under your plan. This can usually be found in the prescription drug section of your online account.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss your need for Stelara as a part of your treatment plan.

Ensure that your healthcare provider understands the necessity for Stelara and is prepared to provide documentation or additional information if required by Amerigroup.

Obtain a Prescription

Your healthcare provider should write a prescription for Stelara, ensuring it specifies the dosing and duration that aligns with your treatment plan.

Maintain a copy of this prescription for your records and to provide to Amerigroup if requested.

Contact Amerigroup Customer Service

Reach out to Amerigroup using the customer service number provided on the back of your insurance card to verify coverage for Stelara and understand any specific requirements that may apply.

Ask about any prior authorization processes you may need to complete for Stelara to be covered under your plan.

Complete Prior Authorization

Follow the steps provided by Amerigroup to complete any necessary prior authorization forms. This may include submitting your prescription and additional documentation from your healthcare provider.

Work closely with your healthcare provider to ensure all required information is complete and accurate to expedite the approval process.

Review and Follow Up

Once the prior authorization is submitted, periodically check the status of your request through the Amerigroup member portal or by contacting customer service.

If approved, confirm with Amerigroup and your pharmacy the steps to proceed with obtaining Stelara.

Utilize Amerigroup's Specialty Pharmacy Network

Amerigroup may require you to obtain Stelara through their specialty pharmacy network. Contact your assigned specialty pharmacy to ensure they have received the authorization and can fill your prescription.

Coordinate the shipment and delivery of Stelara if required and ensure you understand any co-payments or costs you are responsible for.

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FAQs

Does Amerigroup Cover Stelara

Explore Amerigroup's Stelara coverage, reasons for denial, tips to secure coverage, costs without insurance, and frequently asked questions.

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Is Stelara Covered by Amerigroup

Does Amerigroup Cover Stelara?

Amerigroup typically covers Stelara for specific conditions such as moderate to severe plaque psoriasis, active psoriatic arthritis, and moderate to severe Crohn's disease or ulcerative colitis. Prior authorization is commonly required.

Coverage criteria often include a confirmed diagnosis by a healthcare professional, insufficient response or intolerance to other treatments, and medical necessity as documented by your healthcare provider.

Patients might need to provide documented history of their condition and failed attempts with previous medications.

It's essential to consult your specific plan details or contact an Amerigroup representative for precise information, as coverage terms and requirements might vary based on your plan and state regulations.

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Amerigroup's Approved Criteria for Stelara Coverage

General Coverage Criteria for Stelara (Ustekinumab)

Stelara is covered for patients diagnosed with moderate to severe plaque psoriasis (PsO) when the patient is a candidate for systemic therapy or phototherapy.

Coverage is available for individuals with active psoriatic arthritis (PsA), used alone or in combination with methotrexate.

Stelara may be covered for adults with Crohn's disease demonstrating inadequate response or who are intolerant to conventional therapy or a tumor necrosis factor (TNF) blocker.

For patients ages six and older, Stelara is covered for the treatment of moderately to severely active ulcerative colitis (UC) who have demonstrated an inadequate response, loss of response, or intolerance to conventional therapy or a TNF blocker.

Patient Eligibility Criteria

The patient should have a confirmed diagnosis by a healthcare professional according to the conditions mentioned above.

Patients might be required to show considerable evidence of prior treatment failures with other standard or conventional therapies specific to their diagnosis before qualifying for Stelara coverage.

Proof of understanding and adherence capability to the dosage and administration guidelines is essential.

Continuation of Therapy Criteria

Coverage continuation requires documented evidence of clinical benefit, specifically demonstrated improvement or maintenance of baseline clinical symptoms or objective markers of the disease's progression.

Patients must maintain regular consultations with their healthcare provider to monitor efficacy, safety, and compliance with the treatment regimen.

Dosage and Administration Compliance

Coverage is applicable when patients adhere to the prescribed administration schedule approved by their healthcare provider, consistent with FDA labeling and guidelines.

Dosage adjustments are to be made only under the supervision of a licensed healthcare provider.

Special Conditions for Coverage

Approval may require prior authorization or review depending on the individual's therapy history and specific health plan details.

Special consideration for coverage may be placed for patients involved in clinical trials or those with unique health scenarios assessed on a case-by-case basis.

Why Amerigroup Might Deny Stelara Coverage

Situations Where Amerigroup Might Deny Stelara Coverage

**Off-label Uses**: Amerigroup will deny coverage for Stelara if it is prescribed for conditions not approved by the FDA or not listed in the plan's drug coverage policy.

**Lack of Prior Authorization**: If prior authorization is not obtained before the treatment, Amerigroup may deny coverage for Stelara.

**Inadequate Documentation**: Amerigroup requires detailed medical documentation to justify the use of Stelara. Insufficient documentation may lead to denial of coverage.

**Non-Compliance with Step Therapy**: If there is evidence that required step therapy (use of other drugs before Stelara) is not followed, coverage may be denied.

**Policy Exclusions**: If Stelara is excluded under the specific terms of the policy or health plan, Amerigroup may deny coverage.

**Experimental or Investigational Use**: Use of Stelara for experimental or investigational purposes may result in a denial of coverage by Amerigroup.

**Non-Network Providers**: If Stelara is administered by healthcare providers outside of Amerigroup's network—unless specified otherwise in the plan—coverage may be denied.

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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 Amerigroup

Start by Reviewing Your Amerigroup Plan

Access your Amerigroup member portal to review your specific plan details and determine the level of coverage offered for medications, including biologics like Stelara.

Check the formulary list provided by Amerigroup to confirm that Stelara is covered under your plan. This can usually be found in the prescription drug section of your online account.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss your need for Stelara as a part of your treatment plan.

Ensure that your healthcare provider understands the necessity for Stelara and is prepared to provide documentation or additional information if required by Amerigroup.

Obtain a Prescription

Your healthcare provider should write a prescription for Stelara, ensuring it specifies the dosing and duration that aligns with your treatment plan.

Maintain a copy of this prescription for your records and to provide to Amerigroup if requested.

Contact Amerigroup Customer Service

Reach out to Amerigroup using the customer service number provided on the back of your insurance card to verify coverage for Stelara and understand any specific requirements that may apply.

Ask about any prior authorization processes you may need to complete for Stelara to be covered under your plan.

Complete Prior Authorization

Follow the steps provided by Amerigroup to complete any necessary prior authorization forms. This may include submitting your prescription and additional documentation from your healthcare provider.

Work closely with your healthcare provider to ensure all required information is complete and accurate to expedite the approval process.

Review and Follow Up

Once the prior authorization is submitted, periodically check the status of your request through the Amerigroup member portal or by contacting customer service.

If approved, confirm with Amerigroup and your pharmacy the steps to proceed with obtaining Stelara.

Utilize Amerigroup's Specialty Pharmacy Network

Amerigroup may require you to obtain Stelara through their specialty pharmacy network. Contact your assigned specialty pharmacy to ensure they have received the authorization and can fill your prescription.

Coordinate the shipment and delivery of Stelara if required and ensure you understand any co-payments or costs you are responsible for.

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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 Amerigroup Cover Stelara

Explore Amerigroup's Stelara coverage, reasons for denial, tips to secure coverage, costs without insurance, and frequently asked questions.

Achieve Your Goals Faster with Curex