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Does Scripps Health Cover Stelara

Explore Scripps Health coverage for Stelara, reasons for denial, ways to secure coverage, costs without insurance, and a Stelara FAQ.

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Does Scripps Health Cover Stelara?

Scripps Health may cover Stelara, but coverage depends on the specific plan and medical necessity criteria.

Stelara is typically covered for conditions such as moderate to severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.

Prior authorization might be required, meaning your healthcare provider must demonstrate that Stelara is medically necessary for your condition.

Coverage criteria typically include a history of inadequate response or intolerance to traditional therapies for the condition being treated.

The patient may need to try and fail other prescriptions before Stelara is approved; this is often called step therapy.

It is recommended to consult directly with Scripps Health or check your specific health plan details for the most accurate information.

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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 Scripps Health

Understand Stelara and Its Coverage

Research what Stelara is used for, such as treating conditions like psoriasis, psoriatic arthritis, and Crohn's disease.

Ensure you meet the medical necessity as per Scripps Health's coverage guidelines.

Confirm Eligibility with Scripps Health

Contact Scripps Health's customer service to inquire about Stelara coverage under your specific health plan.

Review your health insurance policy documents to understand the terms and coverage specifics for biologic medications like Stelara.

Consult with Your Healthcare Provider

Schedule an appointment with your specialist to discuss your condition and the possible need for Stelara.

Ensure that your healthcare provider is in-network with Scripps Health to facilitate coverage processing.

Obtain a Prescription and Prior Authorization

Your healthcare provider should write a prescription for Stelara and submit a prior authorization request to Scripps Health.

Verify that the prior authorization outlines the necessity and anticipated benefits of Stelara treatment for your condition.

Gather and Submit Necessary Documentation

Collect all required forms and documentation, including any requested medical records and prior authorization approvals.

Coordinate with your healthcare provider’s office and Scripps Health to ensure correct and complete submission of all paperwork.

Work with Scripps Health's Specialty Pharmacy

If your plan involves using a specialty pharmacy, coordinate with Scripps Health’s specialty pharmacy team for medication dispensing.

Ensure delivery logistics and any co-payment arrangements are clearly outlined and agreed upon.

Follow Up and Verify Coverage

Regularly follow up with both your healthcare provider’s office and Scripps Health to confirm that prior authorization and coverage are in place.

Keep records of all communications and approvals for your personal reference.

Contact Scripps Health for Support

If you encounter any issues, contact Scripps Health for assistance and clarification regarding your coverage status.

Reach out to patient advocacy resources provided by Scripps Health if additional support is required.

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FAQs

Does Scripps Health Cover Stelara

Explore Scripps Health coverage for Stelara, reasons for denial, ways to secure coverage, costs without insurance, and a Stelara FAQ.

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Is Stelara Covered by Scripps Health

Does Scripps Health Cover Stelara?

Scripps Health may cover Stelara, but coverage depends on the specific plan and medical necessity criteria.

Stelara is typically covered for conditions such as moderate to severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.

Prior authorization might be required, meaning your healthcare provider must demonstrate that Stelara is medically necessary for your condition.

Coverage criteria typically include a history of inadequate response or intolerance to traditional therapies for the condition being treated.

The patient may need to try and fail other prescriptions before Stelara is approved; this is often called step therapy.

It is recommended to consult directly with Scripps Health or check your specific health plan details for the most accurate information.

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Scripps Health's Approved Criteria for Stelara Coverage

Scripps Health's Approved Criteria for Stelara Coverage

**Diagnosis Confirmation:** The patient must have a confirmed diagnosis by a healthcare professional compatible with FDA-approved indications for Stelara, which include plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis.

**Age Requirement:** The patient should be an adult or pediatric patient as specified in the FDA guidelines for the specific condition being treated with Stelara.

**Treatment History:** The patient should have tried and documented intolerance, contraindication, or inadequate response to at least one conventional therapy for the condition, such as phototherapy for psoriasis or immunosuppressive therapies for Crohn's disease.

**Severity of Disease:** For conditions like plaque psoriasis, the severity should typically be classified as moderate to severe, meaning it affects more than 10% of the body surface area or significantly impacts the patient's quality of life.

**Clinical Documentation:** Provide comprehensive clinical documentation including medical history, previous treatment courses, and current clinical status to justify the medical necessity for using Stelara.

**Specialist Consultation:** Referral and approval from a relevant specialist such as a dermatologist for psoriasis or a gastroenterologist for Crohn's disease or ulcerative colitis might be required to ascertain the appropriateness of Stelara.

**Regular Monitoring:** Agree to regular follow-up visits to evaluate the effectiveness and safety of Stelara treatment, with adjustments made as necessary based on clinical outcomes and any side effects experienced.

**Insurance Evaluation Criteria:** Meet any specific Scripps Health evaluation criteria, which may include step therapy protocols or consideration of the patient's overall health status and other concurrent treatments.

Why Scripps Health Might Deny Stelara Coverage

Non-FDA Approved Uses

Scripps Health may deny coverage for Stelara if it is prescribed for non-FDA approved indications or uses that are considered "off-label".

Lack of Prior Authorization

Coverage could be denied if prior authorization is not obtained where required. Scripps Health requires prior authorization for certain medications, including biologic therapies like Stelara.

Insufficient Clinical Documentation

Insufficient clinical documentation to justify the medical necessity of Stelara can result in denial of coverage. Scripps Health requires comprehensive clinical documentation to substantiate the necessity based on available evidence and guidelines.

Alternative Treatments Not Attempted

If alternative, more conventional treatments have not been attempted or exhausted prior to prescribing Stelara, coverage might be denied. Scripps Health often needs evidence that other treatments have been tried and deemed ineffective.

Non-compliance with Specific Criteria

Claims may be denied if the patient does not meet specific medical criteria defined by Scripps Health for Stelara’s coverage, such as severity of disease or specific patient demographics.

Non-covered Condition

If the condition being treated is not listed under the conditions for which Scripps Health provides coverage for Stelara, such as certain forms of arthritis, psoriasis, or Crohn's/ulcerative colitis, claims might be denied.

Plan Exclusions and Limitations

Denials may occur if the patient's health plan specifically excludes biologics like Stelara or imposes limitations that render the treatment ineligible for coverage under the plan terms.

Non-affiliated Provider

Scripps Health could deny coverage if Stelara is not prescribed or administered by an affiliated provider or within an authorized network, depending on plan specifics.

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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 Scripps Health

Understand Stelara and Its Coverage

Research what Stelara is used for, such as treating conditions like psoriasis, psoriatic arthritis, and Crohn's disease.

Ensure you meet the medical necessity as per Scripps Health's coverage guidelines.

Confirm Eligibility with Scripps Health

Contact Scripps Health's customer service to inquire about Stelara coverage under your specific health plan.

Review your health insurance policy documents to understand the terms and coverage specifics for biologic medications like Stelara.

Consult with Your Healthcare Provider

Schedule an appointment with your specialist to discuss your condition and the possible need for Stelara.

Ensure that your healthcare provider is in-network with Scripps Health to facilitate coverage processing.

Obtain a Prescription and Prior Authorization

Your healthcare provider should write a prescription for Stelara and submit a prior authorization request to Scripps Health.

Verify that the prior authorization outlines the necessity and anticipated benefits of Stelara treatment for your condition.

Gather and Submit Necessary Documentation

Collect all required forms and documentation, including any requested medical records and prior authorization approvals.

Coordinate with your healthcare provider’s office and Scripps Health to ensure correct and complete submission of all paperwork.

Work with Scripps Health's Specialty Pharmacy

If your plan involves using a specialty pharmacy, coordinate with Scripps Health’s specialty pharmacy team for medication dispensing.

Ensure delivery logistics and any co-payment arrangements are clearly outlined and agreed upon.

Follow Up and Verify Coverage

Regularly follow up with both your healthcare provider’s office and Scripps Health to confirm that prior authorization and coverage are in place.

Keep records of all communications and approvals for your personal reference.

Contact Scripps Health for Support

If you encounter any issues, contact Scripps Health for assistance and clarification regarding your coverage status.

Reach out to patient advocacy resources provided by Scripps Health if additional support is required.

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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 Scripps Health Cover Stelara

Explore Scripps Health coverage for Stelara, reasons for denial, ways to secure coverage, costs without insurance, and a Stelara FAQ.

Achieve Your Goals Faster with Curex