Does Blue Shield of California Cover Humira

Explore Blue Shield of California's policies on Humira. Learn why coverage might be denied and discover strategies to secure coverage. Costs and FAQs included.
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Coverage for Humira

 

  • Blue Shield of California may cover Humira as part of its prescription drug benefits. Coverage often requires prior authorization, ensuring the medication is medically necessary.
  •  

  • Humira is typically covered for conditions like rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, and psoriasis.

 

Criteria and Rules

 

  • A healthcare provider must confirm the diagnosis and demonstrate that other treatments have been ineffective.
  •  

  • Renewal of coverage may require proof of the drug’s effectiveness and lack of alternative medications.
  •  

  • Patients often need to meet specific plan requirements, including using Blue Shield's preferred pharmacy network.
  •  

  • Check your specific plan details for copayments, deductibles, and out-of-pocket maximums.

 

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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.

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 Blue Shield of California

 

Check Your Health Plan Details

 

  • Contact Blue Shield of California's customer service or log into your online account to verify coverage specifics for Humira.
  •  

  • Review your policy documents to determine if Humira is included in your list of covered medications.
  •  

  • Understand the tier placement of Humira in your formulary, which affects your co-pay or coinsurance.

 

Consult With Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the necessity of Humira for your condition.
  •  

  • Get a prescription for Humira, ensuring that your doctor includes the necessary medical justification.

 

Complete a Prior Authorization Form

 

  • Download the Prior Authorization form from Blue Shield of California's website or request it from your healthcare provider.
  •  

  • Fill out the form with the required information and obtain your doctor’s signature.
  •  

  • Submit the completed form to Blue Shield of California for review.

 

Verify Specialty Pharmacy Network

 

  • Ensure Humira is available through a specialty pharmacy network supported by Blue Shield of California. This can ensure better pricing and adherence to Blue Shield’s policies.
  •  

  • Contact the specialty pharmacy to understand their process for fulfilling Humira prescriptions and any necessary documentation.

 

Follow-up with Blue Shield of California

 

  • After submission, follow up with Blue Shield of California to inquire about the status of your prior authorization request.
  •  

  • Ensure that you understand any additional steps or documentation needed before approval is granted.

 

Consider Financial Assistance Programs

 

  • If needed, research any financial assistance programs available through AbbVie, the manufacturer of Humira, which might help cover costs not paid by insurance.
  •  

  • Contact Blue Shield of California to see if they have partnerships with such programs to assist in reducing out-of-pocket expenses.

 

Understand Appeals Process

 

  • If your initial request is denied, be prepared to navigate the appeals process with detailed medical reasons and additional documentation.
  •  

  • Consult with your healthcare provider for any additional support or paperwork that may strengthen your appeal case.

 

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FAQs

Does Blue Shield of California Cover Humira

Explore Blue Shield of California's policies on Humira. Learn why coverage might be denied and discover strategies to secure coverage. Costs and FAQs included.
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Is Humira Covered by Blue Shield of California

 

Coverage for Humira

 

  • Blue Shield of California may cover Humira as part of its prescription drug benefits. Coverage often requires prior authorization, ensuring the medication is medically necessary.
  •  

  • Humira is typically covered for conditions like rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, and psoriasis.

 

Criteria and Rules

 

  • A healthcare provider must confirm the diagnosis and demonstrate that other treatments have been ineffective.
  •  

  • Renewal of coverage may require proof of the drug’s effectiveness and lack of alternative medications.
  •  

  • Patients often need to meet specific plan requirements, including using Blue Shield's preferred pharmacy network.
  •  

  • Check your specific plan details for copayments, deductibles, and out-of-pocket maximums.

 

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Blue Shield of California's Approved Criteria for Humira Coverage

 

Criteria for Coverage of Humira

 

  • Humira is covered for the treatment of rheumatoid arthritis when the patient has failed to respond to methotrexate or other disease-modifying antirheumatic drugs (DMARDs).
  •  

  • Coverage is approved for patients with psoriatic arthritis who have not adequately responded to prior DMARD therapy.
  •  

  • Patients with ankylosing spondylitis qualify for Humira coverage following an inadequate response to conventional therapy.
  •  

  • Blue Shield of California covers Humira for those with adult Crohn's disease who have not responded to conventional therapy, including corticosteroids and immunosuppressants.
  •  

  • Humira is approved for individuals 6 years of age and older with moderate to severe Crohn's disease who have failed conventional treatment.
  •  

  • Coverage applies to ulcerative colitis patients who have not responded satisfactorily to corticosteroids and immunosuppressants.
  •  

  • Blue Shield supports Humira use for plaque psoriasis if the patient is 18 years or older and has not responded to prior systemic therapy or phototherapy.
  •  

  • Humira is covered for juvenile idiopathic arthritis in patients aged 2 years or older after an inadequate response to one or more DMARDs.
  •  

  • Patients with non-infectious uveitis who have not responded to conventional therapy may qualify for Humira coverage.

 

Required Documentation

 

  • Documentation confirming the diagnosis and prior therapies for the relevant condition for which Humira is being requested.
  •  

  • Evidence of treatment failure, intolerance, or contraindication with other conventional drugs before approval.
  •  

  • Detailed treatment plan including the intended dose and duration of therapy with Humira.

 

Approval Process

 

  • Healthcare providers must submit a prior authorization request along with all necessary documentation.
  •  

  • Requests are evaluated against Blue Shield of California's clinical criteria for Humira usage.
  •  

  • Upon validation of criteria fulfillment, Humira coverage approval is granted.

 

Continued Coverage Requirements

 

  • Continued coverage is contingent upon regular follow-up and documented clinical benefit from Humira treatment.
  •  

  • Providers need to submit follow-up reports and justify ongoing therapy based on patient outcomes.

 

Why Blue Shield of California Might Deny Humira Coverage

 

Non-FDA Approved Uses

 

  • Blue Shield of California may deny coverage for Humira if it is prescribed for off-label uses that have not been approved by the FDA.

 

Lack of Medical Necessity

 

  • Coverage might be denied if Blue Shield of California determines that Humira is not medically necessary for the patient's condition, based on their medical policy criteria.

 

Inadequate Documentation

 

  • If there's insufficient documentation to support the medical necessity of Humira, such as missing detailed medical records or physician notes, the request for coverage may be denied.

 

Step Therapy Requirements Not Met

 

  • Blue Shield could deny coverage if the patient has not tried or documented the failure of less expensive or alternative medications before seeking approval for Humira.

 

Non-Compliance with Plan Rules

 

  • Failure to adhere to specific plan rules or policies related to specialty medications, such as obtaining Humira through a designated specialty pharmacy, may result in denial of coverage.

 

Policy Exclusions

 

  • If Humira is used for conditions that are explicitly excluded under the patient's policy, the coverage could be denied. This might include specific exclusions outlined in the contract.

 

Eligibility and Enrollment Issues

 

  • Coverage may be denied if there are issues with the patient's eligibility or enrollment status with Blue Shield of California at the time of the prescription request.

 

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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 Blue Shield of California

 

Check Your Health Plan Details

 

  • Contact Blue Shield of California's customer service or log into your online account to verify coverage specifics for Humira.
  •  

  • Review your policy documents to determine if Humira is included in your list of covered medications.
  •  

  • Understand the tier placement of Humira in your formulary, which affects your co-pay or coinsurance.

 

Consult With Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss the necessity of Humira for your condition.
  •  

  • Get a prescription for Humira, ensuring that your doctor includes the necessary medical justification.

 

Complete a Prior Authorization Form

 

  • Download the Prior Authorization form from Blue Shield of California's website or request it from your healthcare provider.
  •  

  • Fill out the form with the required information and obtain your doctor’s signature.
  •  

  • Submit the completed form to Blue Shield of California for review.

 

Verify Specialty Pharmacy Network

 

  • Ensure Humira is available through a specialty pharmacy network supported by Blue Shield of California. This can ensure better pricing and adherence to Blue Shield’s policies.
  •  

  • Contact the specialty pharmacy to understand their process for fulfilling Humira prescriptions and any necessary documentation.

 

Follow-up with Blue Shield of California

 

  • After submission, follow up with Blue Shield of California to inquire about the status of your prior authorization request.
  •  

  • Ensure that you understand any additional steps or documentation needed before approval is granted.

 

Consider Financial Assistance Programs

 

  • If needed, research any financial assistance programs available through AbbVie, the manufacturer of Humira, which might help cover costs not paid by insurance.
  •  

  • Contact Blue Shield of California to see if they have partnerships with such programs to assist in reducing out-of-pocket expenses.

 

Understand Appeals Process

 

  • If your initial request is denied, be prepared to navigate the appeals process with detailed medical reasons and additional documentation.
  •  

  • Consult with your healthcare provider for any additional support or paperwork that may strengthen your appeal case.

 

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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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