Does SelectHealth Cover Humira

Explore insurance details on Humira, reasons for coverage denial by SelectHealth, tips to secure coverage, cost breakdown without insurance, and common FAQs.
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Overview of Humira Coverage by SelectHealth

 

  • SelectHealth may cover Humira, but coverage depends on your specific plan and medical necessity.
  •  

  • Humira is typically covered for treatments of conditions such as rheumatoid arthritis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis, among others.

 

Criteria and Rules for Coverage

 

  • Pre-authorization is often required, meaning your healthcare provider must demonstrate to SelectHealth that Humira is medically necessary for your condition.
  •  

  • The patient typically must have tried and not responded adequately to other treatments before approval is granted for Humira.
  •  

  • Your plan might demand periodic reassessment to continue coverage, ensuring ongoing necessity and efficacy of the treatment.

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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.

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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 SelectHealth

 

Initiate Contact with SelectHealth

 

  • Start by visiting the SelectHealth official website to find contact information. Locate their member services phone number for direct inquiries.
  •  

  • Call SelectHealth customer service and express your interest in obtaining coverage for Humira. Be prepared to provide your member ID and any relevant personal information for verification.
  •  

 

Review Your Health Plan

 

  • Access your SelectHealth member portal or request a copy of your health plan benefits from customer service. Review the section related to prescription drug coverage.
  •  

  • Check if Humira is listed in your plan’s formulary. If not, ask customer service about the process for medications not included in the formulary.
  •  

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider the medical necessity of Humira for your condition. Request a detailed letter of medical necessity to support your case.
  •  

  • Ensure your provider submits any necessary forms or documentation required by SelectHealth to process the coverage request for Humira.
  •  

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to submit a prior authorization request to SelectHealth. This step is crucial to get approval for Humira coverage under your plan.
  •  

  • Include all supporting documentation such as the letter of medical necessity, previous treatment history, and any other relevant medical records.
  •  

 

Appeal if Necessary

 

  • If your prior authorization request is denied, review the denial letter to understand the reason. Follow the appeal process outlined by SelectHealth, which typically involves submitting additional documentation or clarifications.
  •  

  • Consider involving your healthcare provider in the appeal process to strengthen your case for covering Humira.
  •  

 

Stay Informed

 

  • Regularly communicate with SelectHealth representatives to stay updated on the status of your coverage request or appeal.
  •  

  • Track all communications, including dates and the names of representatives spoken to, for future reference if needed.
  •  

 

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FAQs

Does SelectHealth Cover Humira

Explore insurance details on Humira, reasons for coverage denial by SelectHealth, tips to secure coverage, cost breakdown without insurance, and common FAQs.
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Is Humira Covered by SelectHealth

 

Overview of Humira Coverage by SelectHealth

 

  • SelectHealth may cover Humira, but coverage depends on your specific plan and medical necessity.
  •  

  • Humira is typically covered for treatments of conditions such as rheumatoid arthritis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis, among others.

 

Criteria and Rules for Coverage

 

  • Pre-authorization is often required, meaning your healthcare provider must demonstrate to SelectHealth that Humira is medically necessary for your condition.
  •  

  • The patient typically must have tried and not responded adequately to other treatments before approval is granted for Humira.
  •  

  • Your plan might demand periodic reassessment to continue coverage, ensuring ongoing necessity and efficacy of the treatment.

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SelectHealth's Approved Criteria for Humira Coverage

 

Approved Criteria for Humira Coverage

 

  • **Rheumatoid Arthritis (RA):** Must have documented moderate to severe RA. The patient should have tried and failed or had an inadequate response to a disease-modifying antirheumatic drug (DMARD), unless contraindicated.
  •  

  • **Psoriatic Arthritis:** Documentation of active psoriatic arthritis, characterized by swollen, tender joints and possibly skin lesions. Previous trial and failure, contraindication, or intolerance to at least one other medication for the condition.
  •  

  • **Ankylosing Spondylitis (AS):** Diagnosis must be documented and meet the criteria for severe active AS. A history of trial and failure or intolerance to at least one nonsteroidal anti-inflammatory drug (NSAID) is required.
  •  

  • **Crohn's Disease:** Patients must have a confirmed diagnosis of moderate to severe Crohn's Disease. Documentation of previous treatment failure or intolerance to a corticosteroid or an immunosuppressant is necessary, unless contraindicated.
  •  

  • **Ulcerative Colitis:** Proof of moderate to severe ulcerative colitis with prior therapy failure, contraindication, or intolerance to conventional systemic treatments.
  •  

  • **Plaque Psoriasis:** Must have chronic moderate to severe plaque psoriasis affecting body surface area coverage that significantly impacts daily life activities. Failure, intolerance, or contraindication to other systemic therapies should be documented.
  •  

  • **Polyarticular Juvenile Idiopathic Arthritis (JIA):** For patients aged two years or older with documented moderate to severe active polyarticular JIA. Previous trial and failure or intolerance to at least one oral DMARD required.
  •  

 

Why SelectHealth Might Deny Humira Coverage

 

Reasons SelectHealth Might Deny Humira Coverage

 

  • **Non-Approved Indication**: Humira prescribed for conditions that are not FDA-approved may not be covered by SelectHealth.
  •  
  • **Failure to Meet Prior Authorization Requirements**: If prior authorization guidelines are not fulfilled, such as providing necessary medical records or documentation of medical necessity, coverage could be denied.
  •  
  • **Lack of Step Therapy Compliance**: SelectHealth may require evidence that less expensive or alternative therapies have been tried and failed before approving Humira. If this step therapy protocol is not followed, coverage may be denied.
  •  
  • **Absence of Established Diagnosis**: Humira coverage might be denied if there is no documented diagnosis that aligns with SelectHealth's policy criteria for coverage.
  •  
  • **Non-Enrollment in SelectHealth Plan**: Coverage will certainly be denied if the individual is not an active member of a health plan that covers Humira under SelectHealth policies.
  •  
  • **Outside of Plan's Coverage Area**: If Humira is obtained outside of the geographical area that SelectHealth covers, this may lead to denial if it is not part of the health plan's terms of service.
  •  
  • **Non-Compliance with Treatment Guidelines**: Denial can occur if the use of Humira does not comply with the specific treatment guidelines or policies set forth by SelectHealth.
  •  
  • **Ineligible Prescription Source**: Humira prescriptions filled through unapproved providers or pharmacies may be denied for coverage.
  •  
  • **Non-Formulary Drug**: If Humira is not included in the SelectHealth formulary list, it might not be covered unless deemed medically necessary with special exceptions.
  •  

 

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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 SelectHealth

 

Initiate Contact with SelectHealth

 

  • Start by visiting the SelectHealth official website to find contact information. Locate their member services phone number for direct inquiries.
  •  

  • Call SelectHealth customer service and express your interest in obtaining coverage for Humira. Be prepared to provide your member ID and any relevant personal information for verification.
  •  

 

Review Your Health Plan

 

  • Access your SelectHealth member portal or request a copy of your health plan benefits from customer service. Review the section related to prescription drug coverage.
  •  

  • Check if Humira is listed in your plan’s formulary. If not, ask customer service about the process for medications not included in the formulary.
  •  

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider the medical necessity of Humira for your condition. Request a detailed letter of medical necessity to support your case.
  •  

  • Ensure your provider submits any necessary forms or documentation required by SelectHealth to process the coverage request for Humira.
  •  

 

Submit a Prior Authorization Request

 

  • Work with your healthcare provider to submit a prior authorization request to SelectHealth. This step is crucial to get approval for Humira coverage under your plan.
  •  

  • Include all supporting documentation such as the letter of medical necessity, previous treatment history, and any other relevant medical records.
  •  

 

Appeal if Necessary

 

  • If your prior authorization request is denied, review the denial letter to understand the reason. Follow the appeal process outlined by SelectHealth, which typically involves submitting additional documentation or clarifications.
  •  

  • Consider involving your healthcare provider in the appeal process to strengthen your case for covering Humira.
  •  

 

Stay Informed

 

  • Regularly communicate with SelectHealth representatives to stay updated on the status of your coverage request or appeal.
  •  

  • Track all communications, including dates and the names of representatives spoken to, for future reference if needed.
  •  

 

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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.

 

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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 (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.

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