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Does EmblemHealth Cover Stelara

Explore Stelara coverage with EmblemHealth, understand denial reasons, learn how to secure coverage, and discover Stelara costs without insurance.

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Coverage for Stelara Under EmblemHealth

Stelara is typically covered by EmblemHealth for treating conditions like moderate to severe plaque psoriasis, psoriatic arthritis, or Crohn’s disease.

Criteria for Receiving Coverage

Patients must have a diagnosis that aligns with the FDA-approved uses of Stelara.
A history of ineffective treatment or intolerance to conventional therapy may be required.

Basic Rules

Physician’s prior authorization is often necessary to determine medical necessity.
Coverage may be contingent on utilizing a recommended dosage and treatment plan.

Additional Considerations

Patients should consult with their healthcare provider and insurance plan representative for specific details and documentation needed.
Individual plan variations may affect specific coverage terms and any out-of-pocket costs.

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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

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 Stelara Coverage with EmblemHealth

Confirm Coverage Eligibility

Contact EmblemHealth's customer service to verify that Stelara is included in your specific health plan. You can find the contact information on the back of your insurance card or on their official website.

Review your insurance policy documents to understand any specific conditions or requirements for specialty drug coverage.

Consult with Your Healthcare Provider

Discuss with your healthcare provider the necessity of Stelara for your treatment plan. A documented medical necessity is often required to gain coverage.

Ensure that your provider is prepared to furnish any medical records or justifications for the need for Stelara as part of the Prior Authorization process.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a Prior Authorization request to EmblemHealth. This process requires detailed documentation explaining why Stelara is necessary over other treatments.

Ensure that all forms are correctly filled and all supporting documents, such as medical records and prescribed treatment plans, are submitted.

Follow Up on the Prior Authorization

Stay in contact with both EmblemHealth and your healthcare provider to track the status of your Prior Authorization request.

Be prepared to provide any additional information that EmblemHealth might require to approve the request.

Explore Alternative Options

If your request is denied, review the denial notice carefully to understand the reasons. This will help in addressing the concerns if an appeal is necessary.

Consider working with your healthcare provider to file an appeal, supplying any additional documentation that could support the need for Stelara.

Utilize Additional Resources

Check if there are any patient assistance programs offered by the manufacturer of Stelara, which might help cover the costs if insurance falls short.

Consult with a patient advocate at EmblemHealth for further support in navigating the insurance process for specialty drugs.

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Apply treatments in minutes from the comfort of your own home with under-the-tongue applications instead of shots or pills

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Sublingual immunotherapy delivers a higher dose of allergens over the course of treatment.

Potential for results in as few as 6 months

Individual results vary but some users have reported a noticeable difference in as few as 6-12 months since starting treatments

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Studies that have been reviewed by certified physicians show that sublingual immunotherapy is a safe treatment option

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FAQs

Does EmblemHealth Cover Stelara

Explore Stelara coverage with EmblemHealth, understand denial reasons, learn how to secure coverage, and discover Stelara costs without insurance.

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Is Stelara Covered by EmblemHealth

Coverage for Stelara Under EmblemHealth

Stelara is typically covered by EmblemHealth for treating conditions like moderate to severe plaque psoriasis, psoriatic arthritis, or Crohn’s disease.

Criteria for Receiving Coverage

Patients must have a diagnosis that aligns with the FDA-approved uses of Stelara.
A history of ineffective treatment or intolerance to conventional therapy may be required.

Basic Rules

Physician’s prior authorization is often necessary to determine medical necessity.
Coverage may be contingent on utilizing a recommended dosage and treatment plan.

Additional Considerations

Patients should consult with their healthcare provider and insurance plan representative for specific details and documentation needed.
Individual plan variations may affect specific coverage terms and any out-of-pocket costs.

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EmblemHealth's Approved Criteria for Stelara Coverage

EmblemHealth Criteria for Stelara Coverage

**Diagnosis Confirmation**: Patients must have a confirmed diagnosis of one of the following conditions as documented by a healthcare provider:
- Moderate to severe plaque psoriasis
- Active psoriatic arthritis
- Moderate to severe Crohn's disease
- Moderate to severe ulcerative colitis

**Age Requirements**:
- For plaque psoriasis, patients should be 12 years of age or older.
- For Crohn’s disease, ulcerative colitis, and psoriatic arthritis, patients should be adults (18 years and older).

**Previous Treatment History**: Patients must have tried and failed or had an inadequate response to at least one of the following:
- Topical therapies and phototherapy for plaque psoriasis
- Traditional systemic therapies for autoimmune conditions
- Other biologic therapies
Documentation of previous treatment attempts should be included.

**Clinical Evaluation**: A thorough clinical evaluation must show that the use of Stelara is medically necessary for the patient’s condition.

**Dosage and Administration**: Stelara must be used according to the FDA-approved dosing regimen for the specified condition to be eligible for coverage.

**Periodic Evaluation**: Continuous coverage may require documentation of efficacy and re-evaluation by the prescribing healthcare provider, generally every 6 to 12 months.

**Combination Therapy**: Coverage may extend to the use of Stelara in combination with other treatments, as long as they do not contradict FDA guidelines and are deemed necessary by the healthcare provider.

Why EmblemHealth Might Deny Stelara Coverage

Situations When EmblemHealth Might Deny Coverage for Stelara

Stelara is not prescribed for an FDA-approved indication. EmblemHealth may deny coverage if the use of Stelara does not comply with its FDA-approved labels, which include specific conditions like moderate to severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.

Lack of documented medical necessity. EmblemHealth may require comprehensive documentation proving the medical necessity of Stelara for the patient, especially if alternative treatments are available and have not been tried.

Failure to meet prior authorization requirements. EmblemHealth may deny coverage if the necessary prior authorization for Stelara has not been obtained, which typically involves submission of specific clinical information and approval prior to dispensing the medication.

Non-compliance with step therapy protocols. If EmblemHealth's step therapy requirements are not followed, such as trying and failing alternative treatments before Stelara is prescribed, coverage may be denied.

Lack of adherence to dosage and administration guidelines. Coverage can be denied if Stelara is prescribed outside of the recommended dosage or administration guidelines without appropriate justification.

Plan-specific limitations and exclusions. Certain EmblemHealth plans may have specific exclusions or limitations on biological treatments like Stelara, which would result in denial of coverage.

Use of Stelara for cosmetic purposes is not covered. If Stelara is prescribed for cosmetic improvements rather than therapeutic or medically necessary purposes, EmblemHealth will not cover it.

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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 EmblemHealth

Confirm Coverage Eligibility

Contact EmblemHealth's customer service to verify that Stelara is included in your specific health plan. You can find the contact information on the back of your insurance card or on their official website.

Review your insurance policy documents to understand any specific conditions or requirements for specialty drug coverage.

Consult with Your Healthcare Provider

Discuss with your healthcare provider the necessity of Stelara for your treatment plan. A documented medical necessity is often required to gain coverage.

Ensure that your provider is prepared to furnish any medical records or justifications for the need for Stelara as part of the Prior Authorization process.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a Prior Authorization request to EmblemHealth. This process requires detailed documentation explaining why Stelara is necessary over other treatments.

Ensure that all forms are correctly filled and all supporting documents, such as medical records and prescribed treatment plans, are submitted.

Follow Up on the Prior Authorization

Stay in contact with both EmblemHealth and your healthcare provider to track the status of your Prior Authorization request.

Be prepared to provide any additional information that EmblemHealth might require to approve the request.

Explore Alternative Options

If your request is denied, review the denial notice carefully to understand the reasons. This will help in addressing the concerns if an appeal is necessary.

Consider working with your healthcare provider to file an appeal, supplying any additional documentation that could support the need for Stelara.

Utilize Additional Resources

Check if there are any patient assistance programs offered by the manufacturer of Stelara, which might help cover the costs if insurance falls short.

Consult with a patient advocate at EmblemHealth for further support in navigating the insurance process for specialty drugs.

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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 EmblemHealth Cover Stelara

Explore Stelara coverage with EmblemHealth, understand denial reasons, learn how to secure coverage, and discover Stelara costs without insurance.

Achieve Your Goals Faster with Curex