Does Centene Corporation Cover Humira

Explore Centene's Humira coverage: reasons for denial, getting coverage, costs without insurance, and frequently asked questions in this informative guide.
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Centene Corporation Coverage for Humira

 

  • Centene Corporation provides coverage for Humira primarily for conditions such as rheumatoid arthritis, Crohn's disease, ulcerative colitis, and psoriasis when deemed medically necessary.
  •  

  • To get Humira covered, patients often need a documented diagnosis from a healthcare provider, demonstrating that Humira is appropriate for their condition.
  •  

  • Centene might require prior authorization, meaning the doctor must verify that Humira is necessary and potentially more effective than other treatments tried.
  •  

  • In some cases, step therapy is required, where patients must first attempt other approved medications before Humira is authorized.
  •  

  • Coverage specifics can vary by plan, so it is crucial to check the individual policy details and guidelines.
  •  

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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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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 Centene Corporation

 

Research Centene's Coverage Policies

 

  • Visit Centene Corporation's official website to gather detailed information regarding their coverage policies for specialty medications like Humira.
  •  

  • Read through any policy documents or member guides available online to understand their formulary and requirements for drug coverage.

 

Contact Centene Customer Service

 

  • Reach out to Centene's customer service department directly via phone or their online contact form. Request specific information about Humira coverage and any necessary documentation or steps you need to follow.
  •  

  • Inquire about any prerequisites, such as prior authorization, step therapy, or whether Humira is included in the preferred drug list.

 

Consult with Your Healthcare Provider

 

  • Discuss your prescription needs with your doctor or specialist to ensure they understand Centene's requirements for Humira.
  •  

  • If prior authorization is needed, ask your healthcare provider to initiate the process and provide the necessary medical justification for Humira.

 

Complete Required Documentation

 

  • Collect and fill out any forms required by Centene for coverage, such as prior authorization forms or step therapy documentation.
  •  

  • Ensure all medical documentation provided by your healthcare provider is complete and meets Centene's guidelines.

 

Submit Prior Authorization Request

 

  • Work with your healthcare provider to submit all required documentation to Centene for prior authorization.
  •  

  • Track the progress of your submission by contacting Centene regularly to ensure no additional information is needed.

 

Follow Up and Appeal if Necessary

 

  • If your initial coverage request is denied, request a detailed explanation from Centene and explore their appeal process.
  •  

  • Work with your healthcare provider to address any issues or provide additional documentation to support your appeal.

 

Maintain Open Communication

 

  • Keep open lines of communication with Centene and your healthcare provider to address any questions or concerns promptly.
  •  

  • Regularly review your coverage status to ensure that your Humira prescription is continuously covered under your plan.

 

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FAQs

Does Centene Corporation Cover Humira

Explore Centene's Humira coverage: reasons for denial, getting coverage, costs without insurance, and frequently asked questions in this informative guide.
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Is Humira Covered by Centene Corporation

 

Centene Corporation Coverage for Humira

 

  • Centene Corporation provides coverage for Humira primarily for conditions such as rheumatoid arthritis, Crohn's disease, ulcerative colitis, and psoriasis when deemed medically necessary.
  •  

  • To get Humira covered, patients often need a documented diagnosis from a healthcare provider, demonstrating that Humira is appropriate for their condition.
  •  

  • Centene might require prior authorization, meaning the doctor must verify that Humira is necessary and potentially more effective than other treatments tried.
  •  

  • In some cases, step therapy is required, where patients must first attempt other approved medications before Humira is authorized.
  •  

  • Coverage specifics can vary by plan, so it is crucial to check the individual policy details and guidelines.
  •  

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Centene Corporation's Approved Criteria for Humira Coverage

 

Coverage Criteria for Rheumatoid Arthritis

 

  • Patient must have a documented diagnosis of moderate to severe Rheumatoid Arthritis.
  • Patient should have tried and failed, or have an intolerance to at least one Disease-Modifying Antirheumatic Drug (DMARD) before Humira is considered.
  • Humira is approved for use in combination with Methotrexate or as a standalone therapy for cases intolerant to Methotrexate.
  • Clinical evidence or findings of disease progression or inadequate response to prior therapy must be provided.

 

Coverage Criteria for Psoriatic Arthritis

 

  • Patient must exhibit a diagnosis of active Psoriatic Arthritis.
  • Prior treatment should include an inadequate response or contraindication to nonbiologic DMARD therapy.
  • Documentation should support a comprehensive assessment of joint involvement and severity.

 

Coverage Criteria for Crohn's Disease

 

  • Humira is approved for patients aged 6 years and older with moderate to severe Crohn's Disease.
  • Patient should have an inadequate response, intolerance, or contraindication to conventional therapy, such as corticosteroids or immunosuppressants.
  • Clinically significant weight loss, abdominal pain, or assessment findings supporting the severity of disease must be documented.

 

Coverage Criteria for Ankylosing Spondylitis

 

  • Patient diagnosis of active Ankylosing Spondylitis must be present.
  • Patients should have had an inadequate response to or intolerance to one or more non-steroidal anti-inflammatory drugs (NSAIDs).
  • Objective evidence of axial skeleton pathology through imaging or other diagnostic tools must be included.

 

Coverage Criteria for Ulcerative Colitis

 

  • Approval is for patients aged 18 and older with moderate to severe Ulcerative Colitis.
  • Treatment resistance or contraindications to conventional treatments such as aminosalicylates, corticosteroids, or immunosuppressants should be documented.
  • Clinical records should show frequent relapses, sustained symptoms, or complications related to severity.

 

Coverage Criteria for Plaque Psoriasis

 

  • Patient must have chronic moderate to severe Plaque Psoriasis.
  • A history of phototherapy, or inadequate response, intolerance, or contraindication to topical agents should be included.
  • Humira coverage requires documentation showing extensive body surface involvement and significant impairment in daily functioning.

 

Why Centene Corporation Might Deny Humira Coverage

 

Non-FDA Approved Indications

 

  • Centene Corporation may deny coverage for Humira if it is prescribed for conditions or indications that have not been approved by the FDA for this medication.

 

Lack of Medical Necessity

 

  • Humira coverage might be denied if Centene determines that the prescribed use is not medically necessary. This could include situations where alternative treatments are available and more appropriate.

 

Formulary Exclusion

 

  • In cases where Humira is not listed on Centene's formulary, the insurance company may not cover the medication unless special exceptions are made following a detailed review.

 

Non-compliance with Prior Authorization

 

  • Coverage may be denied if the required prior authorization process is not completed. This includes failing to obtain necessary permissions before beginning treatment with Humira.

 

Step Therapy Requirements

 

  • Centene may deny coverage if the patient has not completed a step therapy protocol, which generally involves trying less expensive or preferred medications prior to receiving approval for Humira.

 

Failure to Meet Clinical Guidelines

 

  • Coverage might be denied if the patient does not meet the specific clinical guidelines or criteria set forth by Centene for Humira usage.

 

Non-Participating Provider

 

  • Centene may deny coverage for Humira if the prescribing healthcare provider is outside of the insurance plan's network, unless out-of-network coverage was pre-approved.

 

Experimental or Investigational Use

 

  • If Humira is being used for experimental or investigational purposes, Centene might deny coverage, as such uses typically fall outside of covered benefits.

 

Insurance Plan Exclusions

 

  • Certain insurance plans under Centene may have specific exclusions for biologics like Humira, leading to denial of coverage based on plan rules.

 

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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 Centene Corporation

 

Research Centene's Coverage Policies

 

  • Visit Centene Corporation's official website to gather detailed information regarding their coverage policies for specialty medications like Humira.
  •  

  • Read through any policy documents or member guides available online to understand their formulary and requirements for drug coverage.

 

Contact Centene Customer Service

 

  • Reach out to Centene's customer service department directly via phone or their online contact form. Request specific information about Humira coverage and any necessary documentation or steps you need to follow.
  •  

  • Inquire about any prerequisites, such as prior authorization, step therapy, or whether Humira is included in the preferred drug list.

 

Consult with Your Healthcare Provider

 

  • Discuss your prescription needs with your doctor or specialist to ensure they understand Centene's requirements for Humira.
  •  

  • If prior authorization is needed, ask your healthcare provider to initiate the process and provide the necessary medical justification for Humira.

 

Complete Required Documentation

 

  • Collect and fill out any forms required by Centene for coverage, such as prior authorization forms or step therapy documentation.
  •  

  • Ensure all medical documentation provided by your healthcare provider is complete and meets Centene's guidelines.

 

Submit Prior Authorization Request

 

  • Work with your healthcare provider to submit all required documentation to Centene for prior authorization.
  •  

  • Track the progress of your submission by contacting Centene regularly to ensure no additional information is needed.

 

Follow Up and Appeal if Necessary

 

  • If your initial coverage request is denied, request a detailed explanation from Centene and explore their appeal process.
  •  

  • Work with your healthcare provider to address any issues or provide additional documentation to support your appeal.

 

Maintain Open Communication

 

  • Keep open lines of communication with Centene and your healthcare provider to address any questions or concerns promptly.
  •  

  • Regularly review your coverage status to ensure that your Humira prescription is continuously covered under your plan.

 

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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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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 (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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