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Does Blue Cross Blue Shield of Michigan Cover Stelara

Explore Blue Cross Blue Shield of Michigan's Stelara coverage, costs without insurance, and tips for approval in this comprehensive guide.

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Does Blue Cross Blue Shield of Michigan Cover Stelara?

Stelara is typically covered for conditions such as moderate to severe plaque psoriasis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis.

Coverage is often contingent upon the patient meeting specific criteria, like failing to respond to, or being intolerant of, alternative treatments.

A prior authorization is necessary to confirm that the medication is medically necessary for the patient's condition.

Patients may need to provide documentation of their medical history and previous treatments to qualify for coverage.

It is crucial to check with Blue Cross Blue Shield of Michigan directly or consult their formulary guide for precise coverage details, as policies may vary.

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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 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 Blue Cross Blue Shield of Michigan

Verify Eligibility for Stelara Coverage

Contact Blue Cross Blue Shield of Michigan (BCBSM) customer service using the phone number on your insurance card to inquire about coverage for Stelara.
Request detailed information about any specific plan requirements or prerequisites for obtaining coverage for Stelara, such as prior authorization.

Consult Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss the necessity of Stelara for your condition and obtain a prescription.
Ensure that your healthcare provider is aware of and cooperates with BCBSM's requirements for prescribing Stelara, such as submitting necessary documentation or forms.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a prior authorization request to BCBSM. This may include providing medical records, a detailed treatment plan, and the healthcare provider's justification for prescribing Stelara.
Wait for approval from BCBSM; this process can sometimes take several weeks. Keep in contact with both your provider and BCBSM to check the status of your prior authorization request.

Address Pre-Certification Requirements

Verify if BCBSM requires any pre-certification for Stelara beyond prior authorization. This information can usually be obtained from either your healthcare provider or BCBSM customer service.
If pre-certification is necessary, ensure that your healthcare provider submits this requirement promptly to avoid delays in treatment.

Manage Co-Pay Assistance and Additional Resources

Investigate co-pay assistance programs offered by either the Stelara manufacturer or third-party organizations to help manage out-of-pocket expenses related to Stelara.
Contact BCBSM for information on any additional resources they might provide for expensive specialty medications like Stelara.

Follow Up on Claims and Coverage

Keep track of claims submitted to BCBSM for Stelara and follow up with both your healthcare provider and BCBSM if any issues arise.
If you encounter any denials or partial coverage, appeal the decision by gathering further documentation and resubmitting your case to BCBSM.

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FAQs

Does Blue Cross Blue Shield of Michigan Cover Stelara

Explore Blue Cross Blue Shield of Michigan's Stelara coverage, costs without insurance, and tips for approval in this comprehensive guide.

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Is Stelara Covered by Blue Cross Blue Shield of Michigan

Does Blue Cross Blue Shield of Michigan Cover Stelara?

Stelara is typically covered for conditions such as moderate to severe plaque psoriasis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis.

Coverage is often contingent upon the patient meeting specific criteria, like failing to respond to, or being intolerant of, alternative treatments.

A prior authorization is necessary to confirm that the medication is medically necessary for the patient's condition.

Patients may need to provide documentation of their medical history and previous treatments to qualify for coverage.

It is crucial to check with Blue Cross Blue Shield of Michigan directly or consult their formulary guide for precise coverage details, as policies may vary.

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Blue Cross Blue Shield of Michigan's Approved Criteria for Stelara Coverage

Criteria for Coverage: Stelara Approval by Blue Cross Blue Shield of Michigan

**Diagnosis Requirement:** To be eligible for Stelara coverage, the patient must have a confirmed diagnosis of one of the following conditions: moderate to severe plaque psoriasis, active psoriatic arthritis, moderate to severe Crohn's disease, or moderate to severe ulcerative colitis. Documentation from a healthcare provider attesting to the diagnosis must be provided.

**Age Specifications:** Stelara is covered for adult patients diagnosed with the aforementioned conditions. For pediatric patients, specific criteria apply, and thus prior authorization for patients under age 18 is necessary.

**Previous Treatment:** The patient should have had an inadequate response, intolerance, or contraindication to one or more conventional therapies, such as phototherapy for psoriasis or DMARDs for psoriatic arthritis. This should be supported by medical records or a physician's statement.

**Prescription and Administration:** An adequate prescription from a qualified healthcare professional is necessary. Blue Cross Blue Shield of Michigan covers Stelara when it is administered via the FDA-approved routes and dosages, as per the prescription.

**Trial Duration:** A documented history of trial and failure or clinical evidence suggesting ineffectiveness of other FDA-approved monoclonal antibodies or TNF inhibitors for the prescribed condition is required.

**Regular Monitoring:** Continued coverage of Stelara requires evidence of ongoing monitoring and evaluation of the patient's response to the treatment. Patients must have regular follow-ups with their healthcare providers to ensure treatment efficacy and safety.

**FDA Approval and Guidelines:** The coverage policy aligns with FDA guidelines and approved use cases for Stelara. Any off-label uses may require additional justification and documentation.

Why Blue Cross Blue Shield of Michigan Might Deny Stelara Coverage

Reasons for Denial of Stelara Coverage

Blue Cross Blue Shield of Michigan does not cover Stelara for non-FDA-approved indications or off-label uses. If Stelara is prescribed for a condition not approved by the FDA, coverage may be denied.

Coverage may be denied if the member has not tried and failed on the required number of alternative or less expensive medications before requesting Stelara, often related to step therapy protocols.

Failure to meet specific clinical criteria, such as a confirmed diagnosis or severity of the condition, may result in denial of coverage.

Stelara may not be covered if the prescribed dosage or frequency exceeds FDA-approved recommendations or if it is not determined to be medically necessary.

If the treatment is deemed to be experimental or investigational, it might not be covered due to lack of conclusive clinical evidence regarding its efficacy or safety.

Non-compliance with plan-specific requirements, such as receiving Stelara from a non-preferred provider or specialty pharmacy, might lead to denial.

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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 Blue Cross Blue Shield of Michigan

Verify Eligibility for Stelara Coverage

Contact Blue Cross Blue Shield of Michigan (BCBSM) customer service using the phone number on your insurance card to inquire about coverage for Stelara.
Request detailed information about any specific plan requirements or prerequisites for obtaining coverage for Stelara, such as prior authorization.

Consult Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss the necessity of Stelara for your condition and obtain a prescription.
Ensure that your healthcare provider is aware of and cooperates with BCBSM's requirements for prescribing Stelara, such as submitting necessary documentation or forms.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a prior authorization request to BCBSM. This may include providing medical records, a detailed treatment plan, and the healthcare provider's justification for prescribing Stelara.
Wait for approval from BCBSM; this process can sometimes take several weeks. Keep in contact with both your provider and BCBSM to check the status of your prior authorization request.

Address Pre-Certification Requirements

Verify if BCBSM requires any pre-certification for Stelara beyond prior authorization. This information can usually be obtained from either your healthcare provider or BCBSM customer service.
If pre-certification is necessary, ensure that your healthcare provider submits this requirement promptly to avoid delays in treatment.

Manage Co-Pay Assistance and Additional Resources

Investigate co-pay assistance programs offered by either the Stelara manufacturer or third-party organizations to help manage out-of-pocket expenses related to Stelara.
Contact BCBSM for information on any additional resources they might provide for expensive specialty medications like Stelara.

Follow Up on Claims and Coverage

Keep track of claims submitted to BCBSM for Stelara and follow up with both your healthcare provider and BCBSM if any issues arise.
If you encounter any denials or partial coverage, appeal the decision by gathering further documentation and resubmitting your case to BCBSM.

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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.

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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 Blue Cross Blue Shield of Michigan Cover Stelara

Explore Blue Cross Blue Shield of Michigan's Stelara coverage, costs without insurance, and tips for approval in this comprehensive guide.

Achieve Your Goals Faster with Curex