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Does Regence Cover Stelara

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

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Does Regence Cover Stelara

Coverage for Stelara, a medication used for conditions like plaque psoriasis and Crohn's disease, depends on specific plan benefits.

Pre-authorization is typically required. Your healthcare provider must verify that Stelara is medically necessary for your condition.

Patients often need to have tried other treatments with insufficient response, according to Regence's step therapy criteria.

Coverage may also be contingent on FDA-approved indications for Stelara. Ensure documentation aligns with these approved uses.

Review your individual plan for details on copays, deductibles, and preferred pharmacy networks, as benefits can vary.

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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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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.

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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 Regence

Verify Your Insurance Plan

Contact Regence Customer Service to verify if your insurance plan provides coverage for Stelara.

Review your policy documents or plan details online to confirm whether Stelara can be covered under your plan. You'll need specific details about your policy such as copayments, deductibles, and any applicable restrictions.

Consult Your Healthcare Provider

Discuss with your doctor or healthcare provider the necessity of Stelara for treating your condition. They should provide documentation supporting the medical necessity of Stelara.

Ask your healthcare provider to prepare a prior authorization request, which is often required by insurance companies like Regence to confirm coverage.

Submit a Prior Authorization Request

Your healthcare provider should submit the prior authorization request to Regence on your behalf. This request must include the diagnosis, treatment plan, and justification for using Stelara.

Ensure all required forms and documents are completed accurately and thoroughly to prevent delays in processing.

Follow Up on Your Request

Regularly check with both Regence and your healthcare provider to monitor the status of your prior authorization request. It's crucial to ensure there are no missing documents or additional information required.

If your request is approved, clarify details including copayment amounts, treatment schedules, and any coverage limits that may apply.

Appeal if Necessary

If your request is denied, seek clarification regarding the denial reason. You can often find this information in the denial letter or by contacting Regence Customer Service.

Work with your healthcare provider to prepare an appeal. Provide additional supportive documentation if necessary, addressing the reasons for the initial denial.

Utilize Regence Resources

Use Regence's online portal or account management resources for further assistance with understanding coverage specifics and submitting any necessary documentation.

Reach out to Regence support services, such as a Member Advocate, who can help guide you through the process and offer additional support if needed.

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FAQs

Does Regence Cover Stelara

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

Achieve Your Goals Faster with Curex

Is Stelara Covered by Regence

Does Regence Cover Stelara

Coverage for Stelara, a medication used for conditions like plaque psoriasis and Crohn's disease, depends on specific plan benefits.

Pre-authorization is typically required. Your healthcare provider must verify that Stelara is medically necessary for your condition.

Patients often need to have tried other treatments with insufficient response, according to Regence's step therapy criteria.

Coverage may also be contingent on FDA-approved indications for Stelara. Ensure documentation aligns with these approved uses.

Review your individual plan for details on copays, deductibles, and preferred pharmacy networks, as benefits can vary.

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Regence's Approved Criteria for Stelara Coverage

Regence's Approved Criteria for Stelara Coverage

**Diagnosis of Moderate to Severe Plaque Psoriasis**: Patients must be diagnosed with moderate to severe plaque psoriasis involving at least 10% of the body surface area or significant involvement of sensitive areas, such as the face or hands.

**Previous Treatments**: Candidates should have tried and failed to respond adequately to at least two of the following treatments: phototherapy, systemic therapy like methotrexate or cyclosporine, or have contraindications/intolerance to these treatments.

**Crohn's Disease**: Stelara can be covered for patients with moderately to severely active Crohn's disease who have not responded to, are intolerant of, or have contraindications to conventional Crohn's treatments such as corticosteroids, immunomodulators, or other biologics.

**Ulcerative Colitis**: Coverage is available for those with moderately to severely active ulcerative colitis who have had an inadequate response, loss of response, or intolerance to conventional therapy or a tumor necrosis factor (TNF) blocker.

**Re-evaluation Period**: Stelara coverage requires regular re-evaluation of the patient's response to treatment every 12 months to continue with the therapy. Documentation of treatment effectiveness and patient's progress is necessary.

**Prescribed by a Specialist**: Plan members must have Stelara prescribed by, or in consultation with, a dermatologist, rheumatologist, or gastroenterologist, depending on the condition being treated.

**Dosing Requirements**: Compliance with FDA-approved dosing specifications for Stelara must be ensured, and doses must be administered according to the prescribed intervals for the specific condition.

Why Regence Might Deny Stelara Coverage

Situations Where Regence Might Deny Stelara Coverage

**Non-FDA-Approved Uses**: Coverage may be denied for any off-label use of Stelara that has not been approved by the FDA.

**Failure to Meet Diagnostic Criteria**: Cases where the patient does not have a diagnosis that meets the specified criteria for a covered condition may result in denial.

**Prior Authorization Requirements Not Met**: If prior authorization has not been obtained before initiating treatment, coverage may be denied.

**Inadequate Documentation**: Absence of detailed clinical documentation required to support the medical necessity of Stelara may lead to denial.

**Failure of Alternative Treatments Not Demonstrated**: If the patient has not adequately tried and failed other less costly or more traditional therapies, Regence might deny coverage.

**Plan Exclusions**: Certain health plans might specifically exclude biologics like Stelara or have provisions that limit their coverage.

**Dosage Outside Approved Guidelines**: Stelara prescribed at dosages that fall outside of the established guidelines may not be covered.

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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 Regence

Verify Your Insurance Plan

Contact Regence Customer Service to verify if your insurance plan provides coverage for Stelara.

Review your policy documents or plan details online to confirm whether Stelara can be covered under your plan. You'll need specific details about your policy such as copayments, deductibles, and any applicable restrictions.

Consult Your Healthcare Provider

Discuss with your doctor or healthcare provider the necessity of Stelara for treating your condition. They should provide documentation supporting the medical necessity of Stelara.

Ask your healthcare provider to prepare a prior authorization request, which is often required by insurance companies like Regence to confirm coverage.

Submit a Prior Authorization Request

Your healthcare provider should submit the prior authorization request to Regence on your behalf. This request must include the diagnosis, treatment plan, and justification for using Stelara.

Ensure all required forms and documents are completed accurately and thoroughly to prevent delays in processing.

Follow Up on Your Request

Regularly check with both Regence and your healthcare provider to monitor the status of your prior authorization request. It's crucial to ensure there are no missing documents or additional information required.

If your request is approved, clarify details including copayment amounts, treatment schedules, and any coverage limits that may apply.

Appeal if Necessary

If your request is denied, seek clarification regarding the denial reason. You can often find this information in the denial letter or by contacting Regence Customer Service.

Work with your healthcare provider to prepare an appeal. Provide additional supportive documentation if necessary, addressing the reasons for the initial denial.

Utilize Regence Resources

Use Regence's online portal or account management resources for further assistance with understanding coverage specifics and submitting any necessary documentation.

Reach out to Regence support services, such as a Member Advocate, who can help guide you through the process and offer additional support if needed.

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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 Regence Cover Stelara

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

Achieve Your Goals Faster with Curex