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Does SelectHealth Cover Stelara

Explore SelectHealth coverage for Stelara, reasons for denial, strategies to secure coverage, costs without insurance, and FAQs to guide you.

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SelectHealth Coverage for Stelara

SelectHealth may cover Stelara for patients with moderate to severe plaque psoriasis, active psoriatic arthritis, Crohn's disease, or ulcerative colitis, depending on individual policy specifics.

Prior authorization is typically required. The healthcare provider must demonstrate medical necessity, often by documenting previous treatments tried without sufficient success or intolerable side effects.

Eligibility and Criteria

Patients usually need to meet certain diagnostic criteria, and treatment must be prescribed by a specialist in the relevant field, such as a dermatologist or gastroenterologist.

Coverage decisions may also consider FDA-approved indications and adherence to SelectHealth's clinical guidelines.

Steps to Ensure Coverage

Consult with your healthcare provider to ensure all necessary documentation is in order before submitting for approval.

Contact SelectHealth directly to confirm coverage specifics, as individual plans may 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.

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 SelectHealth

Initial Consultation with Your Healthcare Provider

Discuss your need for Stelara with your healthcare provider. Ensure that Stelara is medically necessary for your condition as your provider will need to support your request with appropriate documentation.

Request your healthcare provider to write a letter or provide a statement justifying the need for Stelara, including your diagnosis and previous treatments tried.

Contact SelectHealth Customer Service

Call SelectHealth customer service to gather preliminary information about your coverage options for Stelara. Have your insurance ID ready for a quicker query.

Make use of SelectHealth’s online member portal or mobile app to access information regarding your coverage benefits specific to prescription drugs.

Review SelectHealth’s Prescription Drug Formulary

Check if Stelara is listed in SelectHealth’s formulary, which is a list of covered prescription medications. This formulary can be accessed through their website or by contacting SelectHealth directly.

If Stelara is not listed, ask about the possibility of getting the medication covered through your plan’s exception or appeal process.

Prior Authorization Process

Stelara typically requires prior authorization. Work with your healthcare provider to submit the necessary prior authorization request forms to SelectHealth, which include medical documentation.

Include your healthcare provider’s statement and any other documentation that supports why Stelara is medically necessary for your condition.

Follow Up on Prior Authorization

Regularly follow up with SelectHealth and your healthcare provider to ensure all required documents have been submitted and to check the status of your prior authorization request.

Inquire about any additional information that may be needed to expedite the approval process.

Appeal Denied Requests If Necessary

If your prior authorization request is denied, review the reason for denial closely. Work with your healthcare provider to address the concerns and gather additional information if needed.

Submit an appeal to SelectHealth if necessary, providing any new evidence or documentation required to support your case for Stelara coverage.

Explore Financial Assistance Options

If coverage through SelectHealth is difficult to obtain or if out-of-pocket expenses are high, consider pharmaceutical manufacturer assistance programs, such as those offered by the makers of Stelara, to lessen financial burden.

Investigate other patient assistance programs or foundation support that may help cover the cost of Stelara in cooperation with your healthcare provider’s office.

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FAQs

Does SelectHealth Cover Stelara

Explore SelectHealth coverage for Stelara, reasons for denial, strategies to secure coverage, costs without insurance, and FAQs to guide you.

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Is Stelara Covered by SelectHealth

SelectHealth Coverage for Stelara

SelectHealth may cover Stelara for patients with moderate to severe plaque psoriasis, active psoriatic arthritis, Crohn's disease, or ulcerative colitis, depending on individual policy specifics.

Prior authorization is typically required. The healthcare provider must demonstrate medical necessity, often by documenting previous treatments tried without sufficient success or intolerable side effects.

Eligibility and Criteria

Patients usually need to meet certain diagnostic criteria, and treatment must be prescribed by a specialist in the relevant field, such as a dermatologist or gastroenterologist.

Coverage decisions may also consider FDA-approved indications and adherence to SelectHealth's clinical guidelines.

Steps to Ensure Coverage

Consult with your healthcare provider to ensure all necessary documentation is in order before submitting for approval.

Contact SelectHealth directly to confirm coverage specifics, as individual plans may vary.

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SelectHealth's Approved Criteria for Stelara Coverage

Criteria for Coverage of Stelara by SelectHealth

**Diagnosis Verification**: The patient must have a confirmed diagnosis of one of the following conditions:
- Moderate to severe plaque psoriasis
- Psoriatic arthritis
- Crohn’s disease
- Ulcerative colitis

**Previous Treatment**: For patients with moderate to severe plaque psoriasis, there must be documentation of an inadequate response, intolerance, or contraindication to other systemic therapies, such as methotrexate, cyclosporine, or phototherapy.

**Age Requirements**: Patients must be of an appropriate age according to the FDA-approved indications, typically 18 years and older, though younger in specific cases for applicable conditions.

**Treatment Plan**: Stelara must be prescribed following an individualized treatment plan created by a qualified healthcare provider and be considered medically necessary.

**Dosage and Administration**: The dosage must comply with FDA guidelines, starting with an induction dose followed by maintenance doses at defined intervals, adjusted as medically necessary.

**Monitoring**: Ongoing monitoring and documentation of the patient’s clinical status to ensure the therapy's continued effectiveness and appropriate administration.

**Comorbidities Assessment**: An evaluation of comorbidities that might affect the treatment process, ensuring Stelara is a suitable therapy option for the patient.

**Provider Qualifications**: The prescribing healthcare provider must be a specialist in the treatment of the specific diagnosed condition, such as a dermatologist, rheumatologist, or gastroenterologist.

**Continuation of Therapy**: For continued approval, there must be documented evidence of benefits from the treatment. This includes improvement in symptoms, quality of life, or maintenance of a therapeutic effect.

Why SelectHealth Might Deny Stelara Coverage

Non-FDA Approved Indications

Stelara coverage is typically denied for any use not approved by the FDA. This includes experimental or investigational use of the medication, even if recommended by a healthcare provider.

Lack of Medical Necessity

Coverage may be denied if the treatment is considered not medically necessary based on clinical evidence and SelectHealth's medical policies. Specifically, if there are not documented attempts of other standard treatments that have been utilized and failed.

Non-Compliance with Prior Authorization Requirements

Stelara prescriptions that have not received proper prior authorization from SelectHealth may be denied. Failing to submit the necessary documentation or improper completion of forms could result in denial.

Excluded Diagnosis Codes

If the patient's diagnosis is not aligned with the approved conditions that SelectHealth covers for Stelara, the claim may be denied. This includes conditions outside of those listed in the policy for autoimmune disorders such as psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis.

No Established Physician-Patient Relationship

Claims might be denied if there is no evidence of an ongoing relationship between the prescribing healthcare provider and the patient, as formal evaluations and follow-ups are necessary to justify Stelara's use.

Failure to Meet Step Therapy Requirements

SelectHealth often requires proof that other cost-effective treatments have been tried and failed before covering Stelara. If there is no documentation of such treatments, coverage can be denied.

Prescription from Out-of-Network Providers

Coverage is potentially denied if Stelara is prescribed by healthcare providers outside the SelectHealth network, unless pre-authorization or special permissions are obtained.

Quantity and Dosage Exceeds Approved Limits

If the prescription exceeds the approved quantity or dosage limits deemed appropriate by SelectHealth policies, coverage might be denied. This ensures proper use and cost management.

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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 SelectHealth

Initial Consultation with Your Healthcare Provider

Discuss your need for Stelara with your healthcare provider. Ensure that Stelara is medically necessary for your condition as your provider will need to support your request with appropriate documentation.

Request your healthcare provider to write a letter or provide a statement justifying the need for Stelara, including your diagnosis and previous treatments tried.

Contact SelectHealth Customer Service

Call SelectHealth customer service to gather preliminary information about your coverage options for Stelara. Have your insurance ID ready for a quicker query.

Make use of SelectHealth’s online member portal or mobile app to access information regarding your coverage benefits specific to prescription drugs.

Review SelectHealth’s Prescription Drug Formulary

Check if Stelara is listed in SelectHealth’s formulary, which is a list of covered prescription medications. This formulary can be accessed through their website or by contacting SelectHealth directly.

If Stelara is not listed, ask about the possibility of getting the medication covered through your plan’s exception or appeal process.

Prior Authorization Process

Stelara typically requires prior authorization. Work with your healthcare provider to submit the necessary prior authorization request forms to SelectHealth, which include medical documentation.

Include your healthcare provider’s statement and any other documentation that supports why Stelara is medically necessary for your condition.

Follow Up on Prior Authorization

Regularly follow up with SelectHealth and your healthcare provider to ensure all required documents have been submitted and to check the status of your prior authorization request.

Inquire about any additional information that may be needed to expedite the approval process.

Appeal Denied Requests If Necessary

If your prior authorization request is denied, review the reason for denial closely. Work with your healthcare provider to address the concerns and gather additional information if needed.

Submit an appeal to SelectHealth if necessary, providing any new evidence or documentation required to support your case for Stelara coverage.

Explore Financial Assistance Options

If coverage through SelectHealth is difficult to obtain or if out-of-pocket expenses are high, consider pharmaceutical manufacturer assistance programs, such as those offered by the makers of Stelara, to lessen financial burden.

Investigate other patient assistance programs or foundation support that may help cover the cost of Stelara in cooperation with your healthcare provider’s office.

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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 SelectHealth Cover Stelara

Explore SelectHealth coverage for Stelara, reasons for denial, strategies to secure coverage, costs without insurance, and FAQs to guide you.

Achieve Your Goals Faster with Curex