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Does Anthem Cover Stelara

Explore why Anthem may deny Stelara, tips to secure coverage, and cost details without insurance in this comprehensive guide.

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Coverage for Stelara with Anthem

Anthem covers Stelara for FDA-approved indications like moderate to severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.

Coverage typically requires prior authorization by Anthem to confirm medical necessity.

Patients must meet specific criteria, such as inadequate response to conventional therapies or being intolerant to them.

Documentation from healthcare providers supporting the diagnosis and previous treatments may be needed for approval.

Check your specific Anthem plan details as coverage varies by plan type and region.

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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.

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 Anthem

Verify Your Insurance Benefits

Contact Anthem customer service to verify your policy covers medications like Stelara. Request detailed benefit information, including co-payment or co-insurance requirements.

Access your member portal on the Anthem website to review your policy documents and benefits related to specialty medications.

Consult Your Healthcare Provider

Ensure your healthcare provider prescribes Stelara for an FDA-approved condition recognized by Anthem to facilitate coverage approval.

Discuss alternatives if Stelara is not covered, or if there are specific conditions for its coverage.

Obtain a Prescription

Have your healthcare provider submit a prescription to a pharmacy that works with your insurance network and is familiar with handling specialty medications.

Discuss with the pharmacy how the medication will be dispensed and what costs you might incur based on your coverage.

Prior Authorization Process

Most health plans, including Anthem, require prior authorization for specialty medications like Stelara. Ensure your provider knows how to complete and submit necessary prior authorization forms to Anthem.

Follow up with your provider’s office to ensure the prior authorization request is submitted correctly and promptly.

Contact Anthem to confirm they received the prior authorization request, and inquire about processing times.

Monitoring Approval Status

Regularly check with Anthem or your provider to get updates on the approval status of Stelara coverage.

Be prepared to provide additional information if Anthem requests more documentation or clarification regarding your treatment necessity.

Appeal If Denied

If Anthem denies coverage, review the reason for denial provided. Work with your healthcare provider to prepare an appeal.

Gather supporting documents, including medical records and letters of medical necessity, to strengthen your appeal.

Submit the appeal within the specified timeframe, ensuring all relevant information accompanies your request.

Explore Financial Assistance Programs

Contact the manufacturer's financial assistance program for Stelara to learn about options for lowering out-of-pocket costs if coverage challenges persist.

Inquire about other nonprofit patient assistance programs that may offer additional support.

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FAQs

Does Anthem Cover Stelara

Explore why Anthem may deny Stelara, tips to secure coverage, and cost details without insurance in this comprehensive guide.

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Is Stelara Covered by Anthem

Coverage for Stelara with Anthem

Anthem covers Stelara for FDA-approved indications like moderate to severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.

Coverage typically requires prior authorization by Anthem to confirm medical necessity.

Patients must meet specific criteria, such as inadequate response to conventional therapies or being intolerant to them.

Documentation from healthcare providers supporting the diagnosis and previous treatments may be needed for approval.

Check your specific Anthem plan details as coverage varies by plan type and region.

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Anthem's Approved Criteria for Stelara Coverage

Criteria for Coverage of Stelara (Ustekinumab)

**Diagnosis of Plaque Psoriasis**: - Member must have a confirmed diagnosis of moderate to severe plaque psoriasis. - Condition should require systemic therapy or phototherapy.

**Diagnosis of Psoriatic Arthritis**: - Member must have an active diagnosis of psoriatic arthritis. - Stelara must be prescribed to reduce the signs and symptoms or inhibit the progression of structural damage.

**Diagnosis of Crohn’s Disease**: - Member must have a confirmed diagnosis of moderate to severe Crohn's disease. - Member should have had an inadequate response to, or be unable to tolerate, conventional therapy including, but not limited to, corticosteroids or immunosuppressants.

**Diagnosis of Ulcerative Colitis**: - Member must have a confirmed diagnosis of moderate to severe ulcerative colitis. - Stelara must be used for induction and maintenance of clinical response and remission, provided previous therapies have been inadequate.

**Prescribing and Monitoring**: - Stelara must be prescribed by or in consultation with a dermatologist, rheumatologist, or gastroenterologist, as appropriate for the condition. - Members must have evaluated baseline liver function tests and be monitored according to standard medical practice for infectious diseases and other conditions relevant to their medical history.

**Age Requirements**: - Member must be 18 years or older for the treatment of plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.

**Previous Treatments**: - Proof of therapeutic failure or clinical intolerance to at least one prior conventional systemic therapy or TNF inhibitor is typically required for Crohn’s disease or ulcerative colitis.

**Limitations**: - The prescribed dose should follow FDA-approved dosing, taking into account any patient-specific factors.

Why Anthem Might Deny Stelara Coverage

Reasons for Denial of Stelara Coverage by Anthem

**Non-Approved Indications:** Anthem may deny coverage if Stelara is prescribed for conditions not approved by the FDA or not included in Anthem's list of covered indications for this medication.

**Dosage and Administration Not Aligned:** If the prescribed dosage or administration frequency does not align with Anthem's clinical guidelines or FDA-approved labeling, coverage may be denied.

**Lack of Prior Authorization:** Coverage might be denied if prior authorization requirements are not met, such as failing to provide necessary documentation or medical justification for using Stelara.

**Absence of Step Therapy:** If the patient has not tried and failed alternative treatments required by Anthem's step therapy policy before using Stelara, the coverage may be denied.

**Experimental or Investigational Use:** Stelara prescribed for experimental or investigational purposes, which are not recognized in Anthem's policy, could lead to a denial of coverage.

**Medical Necessity Not Established:** If Stelara is deemed not medically necessary based on Anthem's criteria or if the documentation fails to establish medical necessity, coverage may be denied.

**Policy Exclusions:** If Stelara falls under specific exclusions in the patient's health plan policy, Anthem may deny coverage. These exclusions might be related to specific conditions, treatments, or usage scenarios outlined in the policy.

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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 Anthem

Verify Your Insurance Benefits

Contact Anthem customer service to verify your policy covers medications like Stelara. Request detailed benefit information, including co-payment or co-insurance requirements.

Access your member portal on the Anthem website to review your policy documents and benefits related to specialty medications.

Consult Your Healthcare Provider

Ensure your healthcare provider prescribes Stelara for an FDA-approved condition recognized by Anthem to facilitate coverage approval.

Discuss alternatives if Stelara is not covered, or if there are specific conditions for its coverage.

Obtain a Prescription

Have your healthcare provider submit a prescription to a pharmacy that works with your insurance network and is familiar with handling specialty medications.

Discuss with the pharmacy how the medication will be dispensed and what costs you might incur based on your coverage.

Prior Authorization Process

Most health plans, including Anthem, require prior authorization for specialty medications like Stelara. Ensure your provider knows how to complete and submit necessary prior authorization forms to Anthem.

Follow up with your provider’s office to ensure the prior authorization request is submitted correctly and promptly.

Contact Anthem to confirm they received the prior authorization request, and inquire about processing times.

Monitoring Approval Status

Regularly check with Anthem or your provider to get updates on the approval status of Stelara coverage.

Be prepared to provide additional information if Anthem requests more documentation or clarification regarding your treatment necessity.

Appeal If Denied

If Anthem denies coverage, review the reason for denial provided. Work with your healthcare provider to prepare an appeal.

Gather supporting documents, including medical records and letters of medical necessity, to strengthen your appeal.

Submit the appeal within the specified timeframe, ensuring all relevant information accompanies your request.

Explore Financial Assistance Programs

Contact the manufacturer's financial assistance program for Stelara to learn about options for lowering out-of-pocket costs if coverage challenges persist.

Inquire about other nonprofit patient assistance programs that may offer additional support.

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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 Anthem Cover Stelara

Explore why Anthem may deny Stelara, tips to secure coverage, and cost details without insurance in this comprehensive guide.

Achieve Your Goals Faster with Curex