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Does Molina Healthcare Cover Stelara

Explore Molina Healthcare's coverage for Stelara, reasons for denial, how to secure coverage, costs without insurance, and answers to common questions.

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Molina Healthcare Coverage for Stelara

Molina Healthcare may cover Stelara for certain conditions such as moderate to severe plaque psoriasis, psoriatic arthritis, and Crohn's disease, depending on their specific health plan policies and state guidelines.

Coverage usually requires prior authorization, demonstrating that Stelara is medically necessary and other treatments have been ineffective or inappropriate for the patient.

Patients may need to meet specific criteria, which typically include diagnosis confirmation by a healthcare provider, documentation of previous treatments tried, and associated responses.

Policy specifics can vary by state or plan type, so reviewing the patient's plan details or contacting Molina Healthcare directly is advisable for precise information relevant to individual cases.

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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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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 Molina Healthcare

Contact Molina Healthcare

Reach out to Molina customer service via phone or email to confirm your policy details and Stelara coverage options.

Ask for any specific forms or documentation needed to process a medication coverage request.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss your need for Stelara.

Ensure your healthcare provider is willing to submit a prior authorization request, as it is often required by insurance companies for specialty medications like Stelara.

Obtain Prior Authorization

Work with your healthcare provider to gather necessary medical records and documentation that justify the need for Stelara.

Submit the prior authorization request through your healthcare provider's office to Molina Healthcare.

Wait for Approval

After submission, contact Molina Healthcare periodically to check the status of your prior authorization request.

Be prepared to provide additional information if Molina requests it during their evaluation process.

Explore Financial Assistance Programs

In case there are coverage limitations or high copayments, contact the manufacturer of Stelara for patient assistance programs or financial aid options.

Check if Molina Healthcare offers any additional financial assistance programs for specialty medications.

Pharmacy Coordination

Once you receive approval, have your healthcare provider send the prescription to a pharmacy that is recognized within the Molina network that can dispense Stelara.

Coordinate with the pharmacy to ensure they have all necessary information provided by Molina Healthcare to process the prescription efficiently.

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Does Molina Healthcare Cover Stelara

Explore Molina Healthcare's coverage for Stelara, reasons for denial, how to secure coverage, costs without insurance, and answers to common questions.

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Is Stelara Covered by Molina Healthcare

Molina Healthcare Coverage for Stelara

Molina Healthcare may cover Stelara for certain conditions such as moderate to severe plaque psoriasis, psoriatic arthritis, and Crohn's disease, depending on their specific health plan policies and state guidelines.

Coverage usually requires prior authorization, demonstrating that Stelara is medically necessary and other treatments have been ineffective or inappropriate for the patient.

Patients may need to meet specific criteria, which typically include diagnosis confirmation by a healthcare provider, documentation of previous treatments tried, and associated responses.

Policy specifics can vary by state or plan type, so reviewing the patient's plan details or contacting Molina Healthcare directly is advisable for precise information relevant to individual cases.

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Molina Healthcare's Approved Criteria for Stelara Coverage

Criteria for Stelara Coverage Under Molina Healthcare

**Diagnosis of Plaque Psoriasis:** Coverage is available for patients aged 18 years and older with a confirmed diagnosis of moderate to severe plaque psoriasis. The condition must be deemed appropriate for systemic therapy or phototherapy.

**Diagnosis of Psoriatic Arthritis:** Patients diagnosed with active psoriatic arthritis seeking Stelara coverage must meet the following criteria: active psoriatic arthritis symptoms and an inadequate response or intolerance to prior therapies such as NSAIDs or DMARDs.

**Diagnosis of Crohn’s Disease:** For patients 18 years or older with moderate to severe Crohn's Disease, coverage is granted when there is an insufficient response, loss of response, or intolerance to other biologic treatments or corticosteroids.

**Diagnosis of Ulcerative Colitis:** Coverage is available for individuals with moderate to severe ulcerative colitis, provided they have experienced an inadequate response to conventional therapy, including corticosteroids, immunomodulators, or tumor necrosis factor (TNF) blockers.

**Demonstrated Need for Biologic Therapy:** Patients must have documented evidence of an inadequate response to, intolerance of, or contraindication to other conventional therapies, such as traditional systemic therapies or other targeted biologic agents.

**Provider Credentials:** Prescribing must be executed by a healthcare provider with relevant specialty experience in managing the condition being treated.

**Treatment Plan Compliance:** Patients should adhere to a clear treatment plan formulated in collaboration with their healthcare provider, including a documented response to initial treatment stages with Stelara before continuation of coverage.

**Reauthorization for Continued Treatment:** Continued coverage requires documented evidence of clinical improvement or stabilization after the initial treatment period, and the treatment plan should be reviewed for ongoing alignment with current clinical guidelines.

Why Molina Healthcare Might Deny Stelara Coverage

Reasons for Stelara Denial by Molina Healthcare

Molina Healthcare may deny coverage for Stelara if the medication is not being prescribed for an FDA-approved indication. It includes any conditions that have not been officially sanctioned by the FDA for Stelara treatment.

Coverage can be denied if the patient does not meet specific medical criteria. For instance, if there is insufficient documentation proving the severity or specific type of the medical condition that requires Stelara.

If prior authorization was not sought or completed correctly, coverage might be denied. This includes failing to submit the necessary paperwork or failing to provide authenticated medical necessity from a healthcare provider.

Molina Healthcare might not cover Stelara if alternative therapies have not been tried first. If there is a policy that requires step therapy and other less expensive treatments have not been attempted, Stelara coverage may not be approved.

The healthcare plan might deny coverage if the prescribing provider is not within the network or lacks the specialization required to justify the need for Stelara.

Denial may occur if the prescription dosage does not align with the approved guidelines. This includes any prescriptions that deviate from the FDA-recommended or authorized dosing schedule.

Patients may face coverage denial if there is a lack of updated or accurate documentation supporting the ongoing need for Stelara treatment.

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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 Molina Healthcare

Contact Molina Healthcare

Reach out to Molina customer service via phone or email to confirm your policy details and Stelara coverage options.

Ask for any specific forms or documentation needed to process a medication coverage request.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss your need for Stelara.

Ensure your healthcare provider is willing to submit a prior authorization request, as it is often required by insurance companies for specialty medications like Stelara.

Obtain Prior Authorization

Work with your healthcare provider to gather necessary medical records and documentation that justify the need for Stelara.

Submit the prior authorization request through your healthcare provider's office to Molina Healthcare.

Wait for Approval

After submission, contact Molina Healthcare periodically to check the status of your prior authorization request.

Be prepared to provide additional information if Molina requests it during their evaluation process.

Explore Financial Assistance Programs

In case there are coverage limitations or high copayments, contact the manufacturer of Stelara for patient assistance programs or financial aid options.

Check if Molina Healthcare offers any additional financial assistance programs for specialty medications.

Pharmacy Coordination

Once you receive approval, have your healthcare provider send the prescription to a pharmacy that is recognized within the Molina network that can dispense Stelara.

Coordinate with the pharmacy to ensure they have all necessary information provided by Molina Healthcare to process the prescription efficiently.

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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 Molina Healthcare Cover Stelara

Explore Molina Healthcare's coverage for Stelara, reasons for denial, how to secure coverage, costs without insurance, and answers to common questions.

Achieve Your Goals Faster with Curex