Does Gateway Health Plan Cover Humira

Explore Humira coverage with Gateway Health Plan, reasons for denial, costs without insurance, and FAQs. Get tips on securing coverage efficiently.
Curex allergy drops unboxing
“Curex is changing the landscape of allergies in 2024”
man opening Curex packaging
man opening Curex packaging

 

Gateway Health Plan Coverage for Humira

 

  • Gateway Health Plan may cover Humira under its pharmacy or medical benefits. Coverage depends on the policy type and medical necessity.
  •  

  • Patients typically require a diagnosis that aligns with approved uses, such as rheumatoid arthritis, psoriasis, or Crohn's disease.
  •  

  • Prior authorization is usually needed. This process involves submitting a request form and supporting medical documentation to demonstrate necessity.
  •  

  • Criteria could include documented failure of or contraindication to other treatments, patient history, and current health status.
  •  

  • Coverage may be subject to tiered co-pays or deductibles, influencing patient out-of-pocket costs.

 

Basic Rules and Criteria

 

  • Ensure that your healthcare provider is familiar with policy requirements and completes all necessary paperwork.
  •  

  • Maintain detailed records of treatment history and previous therapies to support coverage requests.
  •  

  • Regularly review your insurance plan for any changes in formulary or coverage specifics for Humira.

 

Want to try immunotherapy?

Start with Curex

Covered

Uncovered

Treat your allergies with Curex - $49  $9.99

Review your allergy test results with a Curex allergist.

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 Gateway Health Plan

 

Verify Your Eligibility

 

  • Contact Gateway Health Plan directly through their customer service or member services number to confirm if your current health insurance plan covers prescription medications like Humira.
  •  
  • Check your specific plan details by logging into your member portal on Gateway Health Plan's website, where you can review your coverage for prescription drugs.
  •  
  • Ensure that your health condition aligns with the criteria set by Gateway Health Plan for Humira coverage, typically outlined in the plan's policy documents.

 

Get a Prescription from Your Doctor

 

  • Schedule an appointment with your healthcare provider to discuss your condition and the necessity for Humira as part of your treatment plan.
  •  
  • Request your doctor to provide a detailed diagnosis that justifies the need for Humira, which may be required for prior authorization.
  •  
  • Ask if your doctor is willing to assist with the prior authorization process, which is often necessary for specialty drugs like Humira.

 

Submit a Prior Authorization Request

 

  • Work with your doctor’s office to gather all necessary documentation and medical records to support your need for Humira.
  •  
  • Submit a prior authorization request to Gateway Health Plan, usually through your doctor's office. This often involves completing a form provided by the insurer.
  •  
  • Follow up with both your doctor and Gateway Health Plan to ensure the submission was received and is being processed. This can prevent unnecessary delays.

 

Explore Financial Assistance Options

 

  • Inquire about patient assistance programs or co-pay support directly from the manufacturer of Humira (AbbVie), which can help reduce out-of-pocket costs.
  •  
  • Speak to Gateway Health Plan about any additional coverage options, assistance programs, or discounts that may be available for medications like Humira.
  •  
  • Contact non-profit organizations or patient advocacy groups, which may offer support or resources for those needing financial aid for expensive medications.

 

Fill Your Prescription

 

  • If your prior authorization is approved, take your prescription to a pharmacy in your plan's network to fill it under your coverage benefits.
  •  
  • Verify the co-pay amount with your pharmacy when you pick up your Humira prescription to avoid unexpected costs, ensuring that it aligns with your health plan's benefits.
  •  
  • Set up a refill reminder system to manage your medication schedule effectively and ensure uninterrupted treatment.

 

Curex allergy drops unboxing

We love helping people!

Allie, Nevada

five stars

"I have two cats I can finally cuddle!"

Cat and dog allergies

Zachary, Texas

five stars

“I can breathe through my nose for the first time in like 20 years!"

dust allergy
mold allergy

Dust and mold allergies

Erika, New York

five stars

“I've noticed less sneezing and shortness of breath.”

tree allergy
grass allergy

Tree and grass allergies

Richard, Texas

five stars


I love the convenience!

tree allergy

Tree and cat allergies

We Treat Food, Indoor & Outdoor Allergies

tree allergy
Tree Pollens
maple leaf icon
Weed Pollens
Cat Allergies
Dog Allergies
insect icon
Dust Mites
mold allergy
Molds
Food Allergies
 curex user showing allergy treatment kita patient showing allergy treatment boxa male patient showing allergy drops vial
50,000+ users have overcome their allergies
Am I eligible?

Benefits of Curex

At-home treatment

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

5-30x higher cumulative dose vs allergy shots

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

Excellent safety profile

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

Treatment prescribed
by clinician

1
right line icon
Curex packaging

Clinicaly made allergen extracts are customized for your allergies

2
right line icon
insect icon
grass icon
man opening Curex packaging

Your immune system gets desensitized to allergens, giving you long-term relief.

3

FAQs

Does Gateway Health Plan Cover Humira

Explore Humira coverage with Gateway Health Plan, reasons for denial, costs without insurance, and FAQs. Get tips on securing coverage efficiently.
Curex allergy drops unboxing

Is Humira Covered by Gateway Health Plan

 

Gateway Health Plan Coverage for Humira

 

  • Gateway Health Plan may cover Humira under its pharmacy or medical benefits. Coverage depends on the policy type and medical necessity.
  •  

  • Patients typically require a diagnosis that aligns with approved uses, such as rheumatoid arthritis, psoriasis, or Crohn's disease.
  •  

  • Prior authorization is usually needed. This process involves submitting a request form and supporting medical documentation to demonstrate necessity.
  •  

  • Criteria could include documented failure of or contraindication to other treatments, patient history, and current health status.
  •  

  • Coverage may be subject to tiered co-pays or deductibles, influencing patient out-of-pocket costs.

 

Basic Rules and Criteria

 

  • Ensure that your healthcare provider is familiar with policy requirements and completes all necessary paperwork.
  •  

  • Maintain detailed records of treatment history and previous therapies to support coverage requests.
  •  

  • Regularly review your insurance plan for any changes in formulary or coverage specifics for Humira.

 

A weight management program tailored to you

Start with Curex

Gateway Health Plan's Approved Criteria for Humira Coverage

 

Criteria for Coverage of Humira

 

  • **Diagnosed Conditions:** Coverage is provided for individuals diagnosed with autoimmune diseases such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, and plaque psoriasis, among others, when prescribed by a healthcare professional.
  •  

  • **Age Requirements:** The patient must meet certain age criteria as approved by the FDA for the specific condition being treated.
  •  

  • **Prescribing Healthcare Provider:** Humira must be prescribed by a licensed healthcare provider who specializes in treating the specified condition and has experience in prescribing biologic medications.
  •  

  • **Previous Treatments:** The patient may need to demonstrate that they have tried and failed or were intolerant to at least one conventional treatment option or non-biologic therapy relevant to their condition.
  •  

  • **Dosage and Administration:** Humira must be administered according to the recommended dosing schedule for the specific condition being treated, as stipulated by the prescribing information.
  •  

  • **Regular Monitoring:** The patient must be under regular supervision by the prescribing healthcare provider to monitor the effectiveness and any potential side effects of the treatment.
  •  

  • **Insurance Plan Requirements:** The specifics of the insurance plan must be adhered to, including any necessary pre-authorization or documentation that supports the medical need for Humira.

 

Why Gateway Health Plan Might Deny Humira Coverage

 

Denial Due to Lack of Medical Necessity

 

  • Gateway Health Plan may deny Humira coverage if the use of the drug is not deemed medically necessary according to their guidelines.
  •  

  • If there is insufficient documentation to support the need for Humira, a denial could occur.

 

Non-Compliance with Step Therapy Requirements

 

  • Coverage might be denied if the member has not tried other less expensive medications before Humira as part of a step therapy protocol.
  •  

  • If previous treatments have not been documented accurately, it may result in denial.

 

Exclusion of Off-Label Use

 

  • Humira prescribed for conditions not approved by FDA or listed by Gateway Health Plan as a covered condition may lead to coverage denial.
  •  

  • If the condition treated with Humira is not recognized by the plan, coverage can be refused.

 

Expired or Unauthorized Prior Authorization

 

  • If prior authorization for Humira is not obtained or has expired, Gateway Health may deny the claim.
  •  

  • Failure to renew the authorization on time can also result in coverage denial.

 

Non-Adherence to Formularies

 

  • The plan may deny coverage if Humira is not on the approved drug formulary and no exception is granted.
  •  

  • Using a non-preferred brand or strength without justification may lead to denial.

 

Invalid Membership or Coverage Limitations

 

  • Humira coverage could be refused if the individual is no longer eligible for benefits under Gateway Health Plan.
  •  

  • Claims exceeding quantity or dosage limits set by the plan may be denied.

 

Incorrect or Incomplete Claim Information

 

  • Denial may occur if claims submitted have incorrect codes or incomplete patient information.
  •  

  • Errors in billing submissions can cause coverage denial.

 

Failure to Follow Plan Procedures

 

  • Not adhering to proper procedures for obtaining medication, such as failing to use an in-network pharmacy, might result in denial.
  •  

  • Ignoring plan-specific instructions for medication acquisition and administration can cause lack of coverage.

 

Together with our partners we have changed the lives of over 300,000 patients.

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 Gateway Health Plan

 

Verify Your Eligibility

 

  • Contact Gateway Health Plan directly through their customer service or member services number to confirm if your current health insurance plan covers prescription medications like Humira.
  •  
  • Check your specific plan details by logging into your member portal on Gateway Health Plan's website, where you can review your coverage for prescription drugs.
  •  
  • Ensure that your health condition aligns with the criteria set by Gateway Health Plan for Humira coverage, typically outlined in the plan's policy documents.

 

Get a Prescription from Your Doctor

 

  • Schedule an appointment with your healthcare provider to discuss your condition and the necessity for Humira as part of your treatment plan.
  •  
  • Request your doctor to provide a detailed diagnosis that justifies the need for Humira, which may be required for prior authorization.
  •  
  • Ask if your doctor is willing to assist with the prior authorization process, which is often necessary for specialty drugs like Humira.

 

Submit a Prior Authorization Request

 

  • Work with your doctor’s office to gather all necessary documentation and medical records to support your need for Humira.
  •  
  • Submit a prior authorization request to Gateway Health Plan, usually through your doctor's office. This often involves completing a form provided by the insurer.
  •  
  • Follow up with both your doctor and Gateway Health Plan to ensure the submission was received and is being processed. This can prevent unnecessary delays.

 

Explore Financial Assistance Options

 

  • Inquire about patient assistance programs or co-pay support directly from the manufacturer of Humira (AbbVie), which can help reduce out-of-pocket costs.
  •  
  • Speak to Gateway Health Plan about any additional coverage options, assistance programs, or discounts that may be available for medications like Humira.
  •  
  • Contact non-profit organizations or patient advocacy groups, which may offer support or resources for those needing financial aid for expensive medications.

 

Fill Your Prescription

 

  • If your prior authorization is approved, take your prescription to a pharmacy in your plan's network to fill it under your coverage benefits.
  •  
  • Verify the co-pay amount with your pharmacy when you pick up your Humira prescription to avoid unexpected costs, ensuring that it aligns with your health plan's benefits.
  •  
  • Set up a refill reminder system to manage your medication schedule effectively and ensure uninterrupted treatment.

 

Premium Medication you can trust

Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

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.

 

Have questions left?

Get a personalized online consultation with a doctor at Curex

Curex is one of America’s largest telehealth providers

Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
journey now

Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

A weight management program tailored to you

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 (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.

Made in Webflow