Does Florida Blue (Blue Cross Blue Shield of Florida) Cover Humira

Explore Humira coverage by Florida Blue. Learn about possible denial reasons, securing approval, costs without insurance, and FAQs.
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Coverage Criteria for Humira

 

  • Florida Blue may cover Humira for conditions such as rheumatoid arthritis, Crohn's disease, ulcerative colitis, and others, as stated in their policy guidelines.
  •  

  • Patients usually need a confirmed diagnosis for one of these conditions, confirmed via medical documentation.

 

Pre-authorization and Documentation

 

  • Pre-authorization typically required. Physicians must submit medical records demonstrating necessity.
  •  

  • Documentation should include previous treatment attempts and their outcomes.

 

Formulary and Tier System

 

  • Humira's position in the formulary (preferred or non-preferred) affects coverage and out-of-pocket costs.
  •  

  • Higher-tier classification might require higher copays.

 

Step Therapy and Specialist Involvement

 

  • Step therapy protocols may mandate trying less expensive alternatives first before Humira approval.
  •  

  • Specialist consultation often required for approval.

 

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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.

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 Florida Blue (Blue Cross Blue Shield of Florida)

 

Verify Your Policy Coverage

 

  • Contact Florida Blue directly via their customer service or use their online portal to confirm your current level of coverage. Ask specifically about biologic drugs and Humira in particular.
  •  

  • Review your Summary of Benefits and Coverage (SBC) document. This document outlines covered medications and any potential exclusions or limitations.

 

Consult With Your Healthcare Provider

 

  • Speak with your doctor about the necessity of Humira for your treatment plan. They may need to provide clinical justification to your insurance company.
  •  

  • Get a prescription from your healthcare provider that justifies the need for Humira based on your medical condition.

 

Pre-Authorization Process

 

  • Florida Blue may require pre-authorization before covering Humira. Start by having your healthcare provider submit a pre-authorization request.
  •  

  • Ensure all medical documentation and the prescription are submitted with the request to expedite the process.
  •  

  • Follow up with Florida Blue to check the status of your pre-authorization. This can ensure there are no delays or need for additional information.

 

Explore Florida Blue's Drug Formulary

 

  • Check if Humira is listed on Florida Blue's formulary (list of covered medications). This can sometimes be found on their website under member resources.
  •  

  • If Humira is not on the formulary, discuss alternatives with your healthcare provider or explore the process for an exception with Florida Blue.

 

Understand Potential Co-Payments and Financial Assistance

 

  • Check your policy for any co-pay or out-of-pocket costs associated with Humira. This will help in financial planning.
  •  

  • Research if Florida Blue offers any special programs or discounts for expensive medications such as Humira.
  •  

  • Look into manufacturer's assistance programs or non-profit organizations that can help lower the cost of Humira.

 

Appeal a Denial if Necessary

 

  • If coverage is denied, review Florida Blue's appeal process. Gather necessary medical documentation to support your case.
  •  

  • Request a letter of medical necessity from your healthcare provider to strengthen your appeal.
  •  

  • Follow Florida Blue's specified steps for filing an appeal and stay in contact for updates on the status of your appeal.

 

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FAQs

Does Florida Blue (Blue Cross Blue Shield of Florida) Cover Humira

Explore Humira coverage by Florida Blue. Learn about possible denial reasons, securing approval, costs without insurance, and FAQs.
Curex allergy drops unboxing

Is Humira Covered by Florida Blue (Blue Cross Blue Shield of Florida)

 

Coverage Criteria for Humira

 

  • Florida Blue may cover Humira for conditions such as rheumatoid arthritis, Crohn's disease, ulcerative colitis, and others, as stated in their policy guidelines.
  •  

  • Patients usually need a confirmed diagnosis for one of these conditions, confirmed via medical documentation.

 

Pre-authorization and Documentation

 

  • Pre-authorization typically required. Physicians must submit medical records demonstrating necessity.
  •  

  • Documentation should include previous treatment attempts and their outcomes.

 

Formulary and Tier System

 

  • Humira's position in the formulary (preferred or non-preferred) affects coverage and out-of-pocket costs.
  •  

  • Higher-tier classification might require higher copays.

 

Step Therapy and Specialist Involvement

 

  • Step therapy protocols may mandate trying less expensive alternatives first before Humira approval.
  •  

  • Specialist consultation often required for approval.

 

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Florida Blue (Blue Cross Blue Shield of Florida)'s Approved Criteria for Humira Coverage

 

Eligibility Requirements for Humira Coverage

 

  • Patients must have a confirmed diagnosis from a healthcare provider for one of the approved conditions suitable for Humira treatment such as rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, and others as deemed appropriate by Florida Blue.
  •  

  • The treatment must be prescribed by a qualified specialist in the field relevant to the patient's condition, such as a rheumatologist, gastroenterologist, or dermatologist, depending on the indication.

 

Trial of Other Therapies

 

  • The patient should have tried and failed, or shown intolerance to, at least one or more conventional therapies specific to their condition prior to approving Humira treatment. This includes therapies such as methotrexate for rheumatoid arthritis or aminosalicylates for ulcerative colitis.
  •  

  • Medical documentation must be provided to support the necessity of starting Humira treatment based on the failure or inefficacy of prior treatments.

 

Dosage and Administration

 

  • The prescribed dosage of Humira must adhere to the FDA-approved labeling or clinical guidelines specific to the condition being treated. Dosages exceeding these recommendations may require additional documentation and justification for approval.
  •  

  • Continued treatment with Humira may be assessed periodically to ensure therapeutic efficacy, with Florida Blue requiring documentation of clinical improvement or stabilization in the patient’s condition.

 

Approval and Re-authorization Criteria

 

  • Initial approval of Humira treatment is subject to meeting the aforementioned criteria. Approval durations may vary but typically require re-evaluation every 6 to 12 months.
  •  

  • For re-authorization, documentation supporting the continued benefit of Humira therapy is necessary, demonstrating measurable improvement or stabilization of the patient’s condition.

 

Special Considerations

 

  • Florida Blue may consider exceptions based on individual patient circumstances, new medical evidence, or when adequate data supporting alternative use are available, under the discretion of their Clinical Review Board.
  •  

  • Additional coverage may be provided for pediatric conditions or those involving special formulary considerations, with supporting documentation from a pediatric specialist.

 

Why Florida Blue (Blue Cross Blue Shield of Florida) Might Deny Humira Coverage

 

Reasons for Denial of Humira Coverage by Florida Blue

 

  • **Non-Compliance with Prior Authorization Requirements:** Humira coverage may be denied if prior authorization has not been obtained. This is a key step where Florida Blue might assess medical necessity and appropriateness for the prescribed condition.
  •  

  • **Lack of Medical Necessity:** Coverage may be denied if Florida Blue determines that Humira is not medically necessary for the patient's condition according to their specific criteria and guidelines.
  •  

  • **Incomplete or Incorrect Documentation:** Failure to provide complete or accurate medical records and necessary documentation can lead to denial of Humira coverage.
  •  

  • **Alternative Treatments Available:** If Florida Blue assesses that less costly or alternative therapies could be effective for the patient's condition, they might deny Humira coverage.
  •  

  • **Non-Covered Indication:** Humira usage for conditions not covered under the plan, such as experimental or investigational uses, may result in denial.
  •  

  • **Out-of-Network Provider:** If the prescribing physician or healthcare facility is out-of-network, coverage for Humira might be denied unless specific out-of-network benefits apply.
  •  

  • **Plan Exclusions or Limitations:** Coverage can be denied if Humira is specifically excluded from the insurance plan's drug formulary list or falls under a limitation clause.
  •  

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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 Florida Blue (Blue Cross Blue Shield of Florida)

 

Verify Your Policy Coverage

 

  • Contact Florida Blue directly via their customer service or use their online portal to confirm your current level of coverage. Ask specifically about biologic drugs and Humira in particular.
  •  

  • Review your Summary of Benefits and Coverage (SBC) document. This document outlines covered medications and any potential exclusions or limitations.

 

Consult With Your Healthcare Provider

 

  • Speak with your doctor about the necessity of Humira for your treatment plan. They may need to provide clinical justification to your insurance company.
  •  

  • Get a prescription from your healthcare provider that justifies the need for Humira based on your medical condition.

 

Pre-Authorization Process

 

  • Florida Blue may require pre-authorization before covering Humira. Start by having your healthcare provider submit a pre-authorization request.
  •  

  • Ensure all medical documentation and the prescription are submitted with the request to expedite the process.
  •  

  • Follow up with Florida Blue to check the status of your pre-authorization. This can ensure there are no delays or need for additional information.

 

Explore Florida Blue's Drug Formulary

 

  • Check if Humira is listed on Florida Blue's formulary (list of covered medications). This can sometimes be found on their website under member resources.
  •  

  • If Humira is not on the formulary, discuss alternatives with your healthcare provider or explore the process for an exception with Florida Blue.

 

Understand Potential Co-Payments and Financial Assistance

 

  • Check your policy for any co-pay or out-of-pocket costs associated with Humira. This will help in financial planning.
  •  

  • Research if Florida Blue offers any special programs or discounts for expensive medications such as Humira.
  •  

  • Look into manufacturer's assistance programs or non-profit organizations that can help lower the cost of Humira.

 

Appeal a Denial if Necessary

 

  • If coverage is denied, review Florida Blue's appeal process. Gather necessary medical documentation to support your case.
  •  

  • Request a letter of medical necessity from your healthcare provider to strengthen your appeal.
  •  

  • Follow Florida Blue's specified steps for filing an appeal and stay in contact for updates on the status of your appeal.

 

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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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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 (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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