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Does Blue Shield of California Cover Stelara

Explore Blue Shield of California's Stelara coverage, denial reasons, how to secure it, costs without insurance, and find answers to common questions.

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Does Blue Shield of California Cover Stelara?

Blue Shield of California does cover Stelara, a medication used for conditions like plaque psoriasis, psoriatic arthritis, and Crohn’s disease. Coverage depends on medical necessity and specific plan details.

For eligibility, the patient must have a diagnosis approved for Stelara use. Prior treatments are usually required, showing insufficient response or intolerance to other therapies.

Pre-authorization is often required. Patients or providers need to submit documentation to justify the necessity of Stelara.

Generic medications might be preferred before Stelara is covered. Patients should review their plan’s formulary for specific requirements.

Blue Shield’s coverage may vary based on the individual’s specific plan and location, so checking with the plan provider for definitive information is advisable.

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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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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 Blue Shield of California

Gather Necessary Information

Obtain a detailed prescription from your healthcare provider for Stelara, specifying the dosage and condition it treats.

Collect your current insurance information, including your Blue Shield of California member ID and policy details.

Understand Coverage Policies

Visit the Blue Shield of California website to review their formulary, which lists medications and their coverage levels.

Understand the medical necessity criteria for Stelara. Blue Shield may require that Stelara be proven essential to your treatment plan.

Check Prior Authorization Requirements

Consult with Blue Shield regarding any prior authorization necessary for Stelara, which may be required before they cover the medication.

Your healthcare provider may need to submit certain forms or documents demonstrating the need for Stelara.

Contact Blue Shield Customer Service

Call the customer service number found on your insurance card to speak with a representative.

Inquire specifically about coverage for Stelara, including any out-of-pocket costs you might incur.

Coordinate with Your Healthcare Provider

Ask your healthcare provider to liaise directly with Blue Shield, if necessary, to ensure that all required documents and information are submitted.

Your provider may need to provide proof of the medication’s efficacy and necessity specific to your condition.

Follow Up on Authorization

Regularly follow up with Blue Shield to ascertain the status of your Stelara coverage application.

Request written confirmation of coverage once approval is granted.

Consider Financial Assistance Programs

If coverage through Blue Shield is insufficient, research Stelara's manufacturer assistance programs, which might offer additional financial aid.

Consult with a financial advisor or Blue Shield for any secondary insurance options that might cover remaining costs.

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FAQs

Does Blue Shield of California Cover Stelara

Explore Blue Shield of California's Stelara coverage, denial reasons, how to secure it, costs without insurance, and find answers to common questions.

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Is Stelara Covered by Blue Shield of California

Does Blue Shield of California Cover Stelara?

Blue Shield of California does cover Stelara, a medication used for conditions like plaque psoriasis, psoriatic arthritis, and Crohn’s disease. Coverage depends on medical necessity and specific plan details.

For eligibility, the patient must have a diagnosis approved for Stelara use. Prior treatments are usually required, showing insufficient response or intolerance to other therapies.

Pre-authorization is often required. Patients or providers need to submit documentation to justify the necessity of Stelara.

Generic medications might be preferred before Stelara is covered. Patients should review their plan’s formulary for specific requirements.

Blue Shield’s coverage may vary based on the individual’s specific plan and location, so checking with the plan provider for definitive information is advisable.

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Blue Shield of California's Approved Criteria for Stelara Coverage

Coverage Criteria for Stelara

**Diagnosis of Moderate to Severe Plaque Psoriasis**:
- Patient is 18 years of age or older.
- Documented diagnosis of moderate to severe plaque psoriasis.
- Inadequate response or intolerance to previous conventional therapies such as phototherapy, methotrexate, or cyclosporine.

**Diagnosis of Active Psoriatic Arthritis**:
- Patient is 18 years or older.
- Confirmed diagnosis of active psoriatic arthritis.
- Inadequate response, contraindication, or intolerance to one or more traditional Disease-Modifying Antirheumatic Drugs (DMARDs)

**Diagnosis of Crohn’s Disease or Ulcerative Colitis**:
- Patient is 18 years of age or older.
- Diagnosed with moderate to severe Crohn's disease or ulcerative colitis.
- Failure or intolerance to conventional therapies such as corticosteroids, immunomodulators, or tumor necrosis factor (TNF) blockers.

**Initial and Continued Authorization**:
- Initial Authorization: Usually provided for a period of up to 6 months.
- Continued Authorization: Requires documentation of clinical improvement or stability.

**Usage and Administration**:
- Must be prescribed by a dermatologist, rheumatologist, or gastroenterologist.
- Follow the dosage and administration guidelines as per FDA labeling.

Why Blue Shield of California Might Deny Stelara Coverage

Situations Not Covered by Blue Shield of California for Stelara

The request for Stelara is for an off-label use not supported by sufficient clinical evidence or by consensus treatment guidelines.

The patient does not meet the specific diagnostic criteria or severity requirements according to Blue Shield of California's medical policy.

The prescribed use of Stelara is not in compliance with FDA labeling or is for an unapproved dosage.

The medical necessity for Stelara is not demonstrated through relevant medical documentation or tests.

The patient has not tried and failed other preferred treatment options as required by the policy guidelines.

The patient is outside the approved age range for Stelara use according to plan policy.

The prescription exceeds the maximum quantity or length of treatment duration as determined by Blue Shield of California's internal policy limits.

The prescription is being requested for a condition that Blue Shield of California considers experimental or investigational.

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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 Shield of California

Gather Necessary Information

Obtain a detailed prescription from your healthcare provider for Stelara, specifying the dosage and condition it treats.

Collect your current insurance information, including your Blue Shield of California member ID and policy details.

Understand Coverage Policies

Visit the Blue Shield of California website to review their formulary, which lists medications and their coverage levels.

Understand the medical necessity criteria for Stelara. Blue Shield may require that Stelara be proven essential to your treatment plan.

Check Prior Authorization Requirements

Consult with Blue Shield regarding any prior authorization necessary for Stelara, which may be required before they cover the medication.

Your healthcare provider may need to submit certain forms or documents demonstrating the need for Stelara.

Contact Blue Shield Customer Service

Call the customer service number found on your insurance card to speak with a representative.

Inquire specifically about coverage for Stelara, including any out-of-pocket costs you might incur.

Coordinate with Your Healthcare Provider

Ask your healthcare provider to liaise directly with Blue Shield, if necessary, to ensure that all required documents and information are submitted.

Your provider may need to provide proof of the medication’s efficacy and necessity specific to your condition.

Follow Up on Authorization

Regularly follow up with Blue Shield to ascertain the status of your Stelara coverage application.

Request written confirmation of coverage once approval is granted.

Consider Financial Assistance Programs

If coverage through Blue Shield is insufficient, research Stelara's manufacturer assistance programs, which might offer additional financial aid.

Consult with a financial advisor or Blue Shield for any secondary insurance options that might cover remaining costs.

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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 Blue Shield of California Cover Stelara

Explore Blue Shield of California's Stelara coverage, denial reasons, how to secure it, costs without insurance, and find answers to common questions.

Achieve Your Goals Faster with Curex