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Does Cigna Cover Stelara

Explore Cigna's coverage details for Stelara, reasons for denial, tips on securing coverage, costs without insurance, and answers to common questions.

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Overview of Stelara Coverage by Cigna

Cigna may cover Stelara for FDA-approved conditions like moderate to severe plaque psoriasis, active psoriatic arthritis, and Crohn’s disease based on medical necessity.

Typically, patients must have tried and not responded to other treatments before Cigna covers Stelara, showcasing it's a second-line treatment for these conditions.

Basic Coverage Criteria

A healthcare provider must certify that Stelara is necessary after other treatments, specifying how it meets the specific needs of the patient.

Documentation proving prior treatments and the continued symptoms or progression must be provided as part of the request for coverage.

Approval may require prior authorization to ensure that the use of Stelara complies with Cigna’s criteria and policies.

Essential Considerations

Coverage policies can vary based on the specific plan, so reviewing individual policy terms is recommended.

Ongoing communication with the healthcare provider is crucial for changes in treatment plans or if additional documentation is required by Cigna.

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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 Cigna

Verify Your Current Plan Coverage

Log in to your Cigna account or review your insurance policy documents to check if Stelara is included in your current plan's formulary.

Contact Cigna customer service for detailed information on coverage specifics and inquire about potential copayments, deductibles, or any limits on coverage.

Consult Your Healthcare Provider

Speak with your healthcare provider about the medical necessity of Stelara for your condition.

Ensure that they are prepared to provide medical records, treatment history, and a letter of medical necessity if required by Cigna.

Request Prior Authorization

Navigate to the Cigna website or call customer service to obtain the necessary prior authorization forms.

Work with your healthcare provider to complete and submit these forms, along with any supporting documentation, to Cigna.

Follow up regularly with both your healthcare provider and Cigna to monitor the status of your prior authorization request.

Explore Savings Programs

Inquire about any available patient assistance programs or savings cards directly from the manufacturer of Stelara, which may help reduce out-of-pocket costs.

Check with Cigna if they collaborate with any specific assistance programs that can provide additional financial aid.

Appeal Denied Coverage

If Cigna denies coverage, carefully review the denial letter to understand the reasons.

Work with your healthcare provider to gather and submit additional evidence or documentation that may support your case.

Submit an appeal to Cigna and ensure you meet any deadlines set forth in their denial notice.

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Does Cigna Cover Stelara

Explore Cigna's coverage details for Stelara, reasons for denial, tips on securing coverage, costs without insurance, and answers to common questions.

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Is Stelara Covered by Cigna

Overview of Stelara Coverage by Cigna

Cigna may cover Stelara for FDA-approved conditions like moderate to severe plaque psoriasis, active psoriatic arthritis, and Crohn’s disease based on medical necessity.

Typically, patients must have tried and not responded to other treatments before Cigna covers Stelara, showcasing it's a second-line treatment for these conditions.

Basic Coverage Criteria

A healthcare provider must certify that Stelara is necessary after other treatments, specifying how it meets the specific needs of the patient.

Documentation proving prior treatments and the continued symptoms or progression must be provided as part of the request for coverage.

Approval may require prior authorization to ensure that the use of Stelara complies with Cigna’s criteria and policies.

Essential Considerations

Coverage policies can vary based on the specific plan, so reviewing individual policy terms is recommended.

Ongoing communication with the healthcare provider is crucial for changes in treatment plans or if additional documentation is required by Cigna.

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Cigna's Approved Criteria for Stelara Coverage

Cigna Coverage Criteria for Stelara

**Diagnosis Requirement:** The patient must have a confirmed diagnosis of moderate to severe plaque psoriasis, active psoriatic arthritis, Crohn's disease, or ulcerative colitis.

**Age Criteria:** The patient must be 6 years of age or older for the treatment of plaque psoriasis and 18 years or older for Crohn's disease and ulcerative colitis.

**Treatment Experience:** For psoriasis, the patient must have tried and failed or have contraindications to at least two different systemic therapies or phototherapy. For Crohn's disease and ulcerative colitis, the patient must have tried and failed conventional therapies such as corticosteroids or immunomodulators.

**Prescribing Physician:** Treatment with Stelara must be prescribed by, or in consultation with, a dermatologist, rheumatologist, or gastroenterologist, depending on the indication.

**Weight-based Dosing:** For Crohn's disease, patient weight must be considered to determine appropriate induction dosing.

**Previous Biologics:** Patients with Crohn's disease or ulcerative colitis may require documentation of prior use of a TNF inhibitor unless contraindicated.

**Treatment Plan:** There must be an outlined treatment plan, including specific Stelara dosing and frequency tailored to the treatment condition.

**Continuation of Therapy:** Continued coverage of Stelara may require demonstration of treatment efficacy and adherence to the prescribed treatment plan, along with regular follow-ups with the prescribing healthcare provider.

Why Cigna Might Deny Stelara Coverage

Reasons for Stelara Coverage Denial by Cigna

**Non-Approved Indications**: Cigna may deny coverage if Stelara is prescribed for conditions not approved by the FDA or not listed in Cigna's medical coverage policy.

**Incomplete or Insufficient Documentation**: Claims can be denied if the healthcare provider fails to supply adequate documentation of the medical necessity of Stelara. This might include missing or insufficient medical history, lack of diagnosis confirmation, or inadequate progression details of the disease.

**Prior Authorization Not Obtained**: If prior authorization, when required, is not secured before dispensing Stelara, Cigna might reject the claim. This is crucial for ensuring the medication's prescribed use aligns with approved indications and criteria.

**Failure to Meet Clinical Criteria**: Cigna may refuse coverage if the patient does not meet specific clinical criteria outlined in their policy. This includes, but is not limited to, severity of the condition, previous treatments tried, and failure to respond to other therapies before considering Stelara.

**Off-Label Use**: Stelara will not be covered for off-label use unless significant peer-reviewed medical literature supports the use and guidelines, and the treatment is deemed medically necessary. Absent such evidence, coverage is likely to be denied.

**Eligibility Restrictions**: Patients who do not meet particular eligibility requirements, such as specific age restrictions or diagnoses, might have their coverage denied.

**Policy Exclusions and Limitations**: Cigna’s policy may have specific exclusions and limitations regarding biologicals like Stelara. If a prescription falls under these exclusions, coverage will typically be denied.

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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 Cigna

Verify Your Current Plan Coverage

Log in to your Cigna account or review your insurance policy documents to check if Stelara is included in your current plan's formulary.

Contact Cigna customer service for detailed information on coverage specifics and inquire about potential copayments, deductibles, or any limits on coverage.

Consult Your Healthcare Provider

Speak with your healthcare provider about the medical necessity of Stelara for your condition.

Ensure that they are prepared to provide medical records, treatment history, and a letter of medical necessity if required by Cigna.

Request Prior Authorization

Navigate to the Cigna website or call customer service to obtain the necessary prior authorization forms.

Work with your healthcare provider to complete and submit these forms, along with any supporting documentation, to Cigna.

Follow up regularly with both your healthcare provider and Cigna to monitor the status of your prior authorization request.

Explore Savings Programs

Inquire about any available patient assistance programs or savings cards directly from the manufacturer of Stelara, which may help reduce out-of-pocket costs.

Check with Cigna if they collaborate with any specific assistance programs that can provide additional financial aid.

Appeal Denied Coverage

If Cigna denies coverage, carefully review the denial letter to understand the reasons.

Work with your healthcare provider to gather and submit additional evidence or documentation that may support your case.

Submit an appeal to Cigna and ensure you meet any deadlines set forth in their denial notice.

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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 Cigna Cover Stelara

Explore Cigna's coverage details for Stelara, reasons for denial, tips on securing coverage, costs without insurance, and answers to common questions.

Achieve Your Goals Faster with Curex