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Does Presbyterian Healthcare Services Cover Stelara

Explore why Stelara may not be covered, tips for obtaining coverage, costs without insurance, and answers to common Stelara questions with Presbyterian Healthcare Services.

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Does Presbyterian Healthcare Services Cover Stelara?

Presbyterian Healthcare Services may cover Stelara (ustekinumab), but coverage depends on the specific insurance plan and medical necessity.

Stelara is generally used for treating moderate to severe plaque psoriasis, psoriatic arthritis, and Crohn's disease. Coverage is contingent on FDA-approved indications.

Prior authorization is typically required to ensure the treatment is necessary and meets specific medical criteria. This usually includes documented failure or intolerance to conventional therapies.

Patients must have a prescription from a healthcare provider to initiate the process for coverage approval. The provider often needs to submit clinical documentation to support the request.

Benefits, co-pays, and out-of-pocket costs vary, so it’s crucial to review the individual insurance policy details or contact Presbyterian Healthcare Services directly for personalized information.

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Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Stelara Coverage with Presbyterian Healthcare Services

Contact Presbyterian Healthcare Services

Call the customer service number found on the back of your insurance card to inquire about coverage for Stelara. You can also visit the Presbyterian Healthcare Services website for more contact options.

Request detailed information about your current health plan to understand pharmacy benefits and whether Stelara is covered.

Consult with Your Healthcare Provider

Discuss your need for Stelara with your healthcare provider. They might have experience with obtaining insurance approval for similar prescriptions and can offer advice tailored to your plan.

Ensure your healthcare provider documents the medical necessity of Stelara in your medical records and any communications with Presbyterian Healthcare Services. This documentation can be critical for insurance approval.

Gather Required Documentation

Request a prior authorization form from Presbyterian Healthcare Services if it's required for Stelara coverage. Your healthcare provider will often complete this, but you should provide any necessary personal and insurance information.

Compile any relevant medical records, physician's notes, and test results that support the need for Stelara with your provider's assistance.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a complete prior authorization request to Presbyterian Healthcare Services. Include all necessary documentation that supports the necessity of Stelara for your condition.

Follow up with Presbyterian Healthcare Services after submission to ensure they received all required documents and to check on the status of your request.

Monitor Approval Status

Keep in regular contact with Presbyterian Healthcare Services. They can provide updates on the status of your prior authorization request.

If the request is denied, ask for the specific reasons and consult both your provider and Presbyterian Healthcare Services on steps for an appeal. Gathering additional supporting documents can be helpful during an appeal.

Receive Medications

Once approved, confirm with both your pharmacy and Presbyterian Healthcare Services to ensure they have processed the coverage, so there are no issues when filling your prescription.

Pick up Stelara from your pharmacy, verifying that it is correctly billed under your insurance with the agreed copay or coverage terms.

Maintain Ongoing Communication

Regularly monitor your insurance claims and statements to ensure Stelara is consistently covered as per the terms discussed.

Stay in contact with Presbyterian Healthcare Services and your healthcare provider to manage any future authorizations or changes in coverage terms.

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Does Presbyterian Healthcare Services Cover Stelara

Explore why Stelara may not be covered, tips for obtaining coverage, costs without insurance, and answers to common Stelara questions with Presbyterian Healthcare Services.

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Is Stelara Covered by Presbyterian Healthcare Services

Does Presbyterian Healthcare Services Cover Stelara?

Presbyterian Healthcare Services may cover Stelara (ustekinumab), but coverage depends on the specific insurance plan and medical necessity.

Stelara is generally used for treating moderate to severe plaque psoriasis, psoriatic arthritis, and Crohn's disease. Coverage is contingent on FDA-approved indications.

Prior authorization is typically required to ensure the treatment is necessary and meets specific medical criteria. This usually includes documented failure or intolerance to conventional therapies.

Patients must have a prescription from a healthcare provider to initiate the process for coverage approval. The provider often needs to submit clinical documentation to support the request.

Benefits, co-pays, and out-of-pocket costs vary, so it’s crucial to review the individual insurance policy details or contact Presbyterian Healthcare Services directly for personalized information.

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Presbyterian Healthcare Services's Approved Criteria for Stelara Coverage

Criteria for Coverage of Stelara

**Diagnosis Requirement**: Patients must have a confirmed diagnosis of one of the following conditions: - Moderate to severe plaque psoriasis in adults or adolescents 12 years and older. - Active psoriatic arthritis in adults. - Moderately to severely active Crohn's Disease in adults or pediatric patients 6 years and older. - Moderately to severely active ulcerative colitis in adults.

**Treatment History**: For conditions other than plaque psoriasis, there must be documentation of inadequate response, intolerance, or contraindication to conventional therapies: - For Crohn's Disease and Ulcerative Colitis: Corticosteroids, Immunomodulators, or TNF blockers. - For Psoriatic Arthritis: Non-biologic DMARDs such as methotrexate or sulfasalazine.

**Age Restriction**: The patient must meet the age requirements specified for each condition for which Stelara is approved.

**FDA-approved Indication**: Stelara must be prescribed within its FDA-approved indications for the patient’s specified condition.

**Previous Biologic Use**: The patient should have experienced an inadequate response or intolerance to at least one other biologic therapy unless Stelara is the preferred initial biologic agent for the condition, based on the latest treatment guidelines or payer formulary.

**Specialist Conduct**: The prescribing physician must be a specialist in the disease being treated, such as a dermatologist, gastroenterologist, or rheumatologist, or have consulted with an appropriate specialist.

**Intent of Use**: The primary intention for Stelara use should be therapeutic treatment and not prevention or prophylactic use.

Why Presbyterian Healthcare Services Might Deny Stelara Coverage

Reasons for Denial of Stelara Coverage by Presbyterian Healthcare Services

**Non-FDA Approved Indications:** Coverage is denied if Stelara is prescribed for conditions that are not approved by the Food and Drug Administration (FDA).

**Cosmetic Use:** Stelara is not covered if it is administered for conditions deemed cosmetic, rather than medical, by the healthcare provider.

**Experimental or Investigational Use:** The treatment is denied if determined to be experimental or investigational for the specific condition and patient, lacking sufficient clinical evidence of its effectiveness.

**Off-Label Use Without Supporting Evidence:** Stelara prescriptions for off-label use are not covered unless there is compelling evidence from peer-reviewed medical literature supporting its efficacy and safety for those uses.

**Failure to Meet Specific Clinical Criteria:** Coverage is refused if the patient does not meet specific clinical criteria set by Presbyterian Healthcare Services, such as prior treatment requirements or severity of condition.

**Non-compliance with Step Therapy Requirements:** Denial occurs if the patient has not previously tried and failed other specified medications, per step therapy protocols or formulary guidelines.

**Inadequate Documentation of Medical Necessity:** If a healthcare provider fails to adequately document the medical necessity for Stelara, coverage can be denied.

**Lack of Plan Authorization:** Coverage is not granted if prior authorization is not obtained as required by the patient's specific health plan. Lack of pre-approval or failure to follow authorization procedures results in denial.

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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 Presbyterian Healthcare Services

Contact Presbyterian Healthcare Services

Call the customer service number found on the back of your insurance card to inquire about coverage for Stelara. You can also visit the Presbyterian Healthcare Services website for more contact options.

Request detailed information about your current health plan to understand pharmacy benefits and whether Stelara is covered.

Consult with Your Healthcare Provider

Discuss your need for Stelara with your healthcare provider. They might have experience with obtaining insurance approval for similar prescriptions and can offer advice tailored to your plan.

Ensure your healthcare provider documents the medical necessity of Stelara in your medical records and any communications with Presbyterian Healthcare Services. This documentation can be critical for insurance approval.

Gather Required Documentation

Request a prior authorization form from Presbyterian Healthcare Services if it's required for Stelara coverage. Your healthcare provider will often complete this, but you should provide any necessary personal and insurance information.

Compile any relevant medical records, physician's notes, and test results that support the need for Stelara with your provider's assistance.

Submit a Prior Authorization Request

Work with your healthcare provider to submit a complete prior authorization request to Presbyterian Healthcare Services. Include all necessary documentation that supports the necessity of Stelara for your condition.

Follow up with Presbyterian Healthcare Services after submission to ensure they received all required documents and to check on the status of your request.

Monitor Approval Status

Keep in regular contact with Presbyterian Healthcare Services. They can provide updates on the status of your prior authorization request.

If the request is denied, ask for the specific reasons and consult both your provider and Presbyterian Healthcare Services on steps for an appeal. Gathering additional supporting documents can be helpful during an appeal.

Receive Medications

Once approved, confirm with both your pharmacy and Presbyterian Healthcare Services to ensure they have processed the coverage, so there are no issues when filling your prescription.

Pick up Stelara from your pharmacy, verifying that it is correctly billed under your insurance with the agreed copay or coverage terms.

Maintain Ongoing Communication

Regularly monitor your insurance claims and statements to ensure Stelara is consistently covered as per the terms discussed.

Stay in contact with Presbyterian Healthcare Services and your healthcare provider to manage any future authorizations or changes in coverage terms.

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Stelara FAQ

What are the common side effects of Stelara?

Common Side Effects of Stelara

**Infections:** Increased susceptibility to infections such as upper respiratory infections and strep throat.
**Headache:** This is a frequently reported side effect among patients who use Stelara.
**Tiredness:** Many individuals may experience fatigue or tiredness while on this medication.
**Redness at Injection Site:** Skin irritation, including redness, itching, or swelling, can occur at the site of injection.
**Nausea:** Some patients report feeling mildly nauseated after taking the medication.

How does Stelara work for psoriasis?

Mechanism of Action

Stelara is a monoclonal antibody that targets interleukin-12 (IL-12) and interleukin-23 (IL-23), which are proteins involved in inflammatory processes associated with psoriasis.

Impact on the Immune System

By inhibiting IL-12 and IL-23, Stelara reduces the activity of specific immune cells (T-cells) that contribute to the inflammation and rapid skin cell production characteristic of psoriasis.

Clinical Efficacy

Many patients experience significant reductions in psoriasis symptoms, including skin clearance, with improvements often visible within weeks after initial treatment.

Administration and Dosage

Stelara is administered via subcutaneous injection, starting with a loading dose followed by maintenance doses every 12 weeks thereafter.

How often do you need Stelara injections?

Stelara Injection Schedule

Initial Doses: After the first dose is administered, a second dose follows four weeks later.

Maintenance Doses: Subsequent injections are given every 12 weeks.

Special Cases: Depending on specific conditions like Crohn's disease, the frequency may vary under a physician's guidance.

Administration: Stelara is typically administered as a subcutaneous injection which can be performed in a healthcare setting or self-administered after proper training.

Consult Your Doctor: Always consult with your healthcare provider to tailor the schedule to your medical needs.

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Initial Dosage

Your initial medication and dosage are carefully determined by doctors, taking into account your unique health profile. This ensures a personalized and safe treatment plan tailored to your specific needs.

Titration

We gradually adjust your dosage to reach the optimal therapeutic level, ensuring maximum effectiveness while minimizing potential side effects.

Additional Treatments

Our providers may also recommend medications such as metformin or supplements such as vitamin B12. We recognize the importance of managing side effects, so your care plan may include medication to alleviate them.

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Do your plans include prescriptions and medications?

Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you. Our service includes continuous support and regular follow-ups to ensure your treatment stays on track.

Our clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance.

Please note: Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.

What medications do your providers prescribe?

We prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide. Our providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster.

Depending on your treatment goals, other medications such as metformin may also be considered. We recognize the importance of managing side effects, so your care plan might include medication to ease symptoms like nausea. Your well-being is always our top priority!

Please note that compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness. A prescription is necessary. Results may vary from person to person.

Curex and its pharmacy partners do not have any association with Novo Nordisk.

Will I be prescribed semaglutide?

Your health journey is unique, and we tailor our care to match. Any prescriptions, including semaglutide, will be based on the expert assessment of the medical provider matched with you through our platform. You can trust that your treatment plan will be personalized to fit your specific needs. And if semaglutide is not prescribed, we will provide a full refund.

What is compounded medication?

Compounding involves creating customized medications to meet the specific needs of individual patients. For instance, a patient may require a liquid version of a medication that is only available in tablet form. Pharmacies can also compound medications using FDA-approved drugs that are on the FDA’s shortage list.

These compounded medications are made by state-licensed pharmacies that follow both federal and state regulations, including quality standards. However, when compounded in accordance with these laws, these medications are not subject to FDA approval and are not evaluated for safety or effectiveness.

Is compounded medication the same as generic medication?

Compounded medications differ from generic drugs. Generics require FDA approval by demonstrating bio-equivalence to the brand-name drug. In contrast, compounded medications are not FDA-approved. They are made based on a personalized prescription that may not be commercially available elsewhere or when a drug appears on the FDA’s shortage list. Compounding pharmacies must have the proper licensed facilities and comply with state and federal regulations before dispensing these medications.

Is insurance required?

No, Curex doesn’t require insurance. We offer clear and simple pricing, along with affordable medication options, making it easy and accessible to take care of your health.

Can I pay with an FSA or HSA card?

Yes! You can pay with your HSA or FSA card.

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. We don’t prescribe Ozempic®* or Wegovy®.* We may prescribe treatments containing compounded semaglutide or tirzepatide. These medications are specially compounded for you by a licensed pharmacy to meet your specific needs.

Are video visits with a provider required?

Our providers will review your information 100% online. Depending on where you live and the specifics of your medical history, our providers may require you to have a video visit or asynchronous visit via text message. If prescribed, you’ll get unlimited online access to message your provider as needed for follow-ups, adjustments, and answers to your questions.

What states do you serve?

Currently, we do not serve Arkansas, Connecticut, and New Mexico. However, we are always working to expand our reach, so stay in touch with us at hi@getcurex.com.

Does Presbyterian Healthcare Services Cover Stelara

Explore why Stelara may not be covered, tips for obtaining coverage, costs without insurance, and answers to common Stelara questions with Presbyterian Healthcare Services.

Achieve Your Goals Faster with Curex