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Does SummaCare Cover Humira

Explore SummaCare's Humira coverage: reasons for denial, how to get it, costs without insurance, and answers to common questions in this informative article.
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Does SummaCare Cover Humira?

 

  • SummaCare does offer coverage for Humira under certain plans, primarily within their commercial and Medicare offerings. Eligibility and coverage details depend on your specific plan.

    •  

  • To have Humira covered, a prescription from a healthcare provider is generally required. The prescription must specify that Humira is medically necessary for treating conditions like rheumatoid arthritis, Crohn's disease, or psoriasis.

    •  

  • SummaCare might require prior authorization, which involves a review of the medical necessity and appropriateness of Humira for the patient's condition. It's vital to consult with SummaCare for the requirements of your specific plan.

    •  

  • Consider using SummaCare's network pharmacies and preferred vendors to minimize out-of-pocket costs. Understanding tier levels in the plan can also help manage expenses related to Humira.

    •  

 

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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

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 SummaCare

 

Verify Your Plan Coverage

 

  • Contact SummaCare directly by calling the customer service number on your insurance card to confirm if Humira is included in your plan's formulary.

    •  

  • Log into your SummaCare member account online to access your plan details and review the formulary list yourself.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Humira and obtain any necessary documentation, such as a prescription or prior authorization.

    •  

  • Ensure your healthcare provider knows your plan specifics to provide any required information to SummaCare for coverage approval.

 

Obtain Prior Authorization

 

  • Work with your healthcare provider to complete and submit any required prior authorization forms to SummaCare. This step is crucial as Humira is often a medication that requires this pre-approval.

    •  

  • Follow up with your healthcare provider or SummaCare to ensure the prior authorization process is complete and approved.

 

Explore Financial Assistance Programs

 

  • Ask your healthcare provider about any pharmaceutical assistance programs offered by the manufacturer of Humira for additional support if coverage challenges arise.

    •  

  • Visit the official Humira website or contact their support line to inquire about patient assistance programs that might subsidize your medication costs.

 

Fill Your Prescription

 

  • Once SummaCare approves your Humira coverage, take your prescription to an in-network pharmacy preferred by SummaCare or use their mail-order service if available.

    •  

  • Verify with the pharmacy that your coverage is applied correctly during the filling process to avoid unexpected costs.

 

Regularly Review and Renew Authorization

 

  • Check if your coverage or authorization requires renewal periodically, and proactively initiate renewal processes to avoid lapses in your Humira therapy.

    •  

  • Stay updated with any changes in SummaCare's formulary or coverage policies that might affect your Humira coverage.

 

Reach Out for Support

 

  • Contact SummaCare's customer service or a dedicated care coordinator for any assistance in navigating the coverage process or addressing any issues.

    •  

  • Seek advice from patient advocacy groups or resources specializing in insurance issues for additional guidance.

 

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FAQs

Does SummaCare Cover Humira

Explore SummaCare's Humira coverage: reasons for denial, how to get it, costs without insurance, and answers to common questions in this informative article.
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Is Humira Covered by SummaCare

 

Does SummaCare Cover Humira?

 

  • SummaCare does offer coverage for Humira under certain plans, primarily within their commercial and Medicare offerings. Eligibility and coverage details depend on your specific plan.

    •  

  • To have Humira covered, a prescription from a healthcare provider is generally required. The prescription must specify that Humira is medically necessary for treating conditions like rheumatoid arthritis, Crohn's disease, or psoriasis.

    •  

  • SummaCare might require prior authorization, which involves a review of the medical necessity and appropriateness of Humira for the patient's condition. It's vital to consult with SummaCare for the requirements of your specific plan.

    •  

  • Consider using SummaCare's network pharmacies and preferred vendors to minimize out-of-pocket costs. Understanding tier levels in the plan can also help manage expenses related to Humira.

    •  

 

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SummaCare's Approved Criteria for Humira Coverage

 

Criteria for Humira Coverage

 

  • SummaCare covers Humira for patients who have been diagnosed with moderate to severe rheumatoid arthritis and have exhibited an inadequate response to one or more traditional disease-modifying antirheumatic drugs (DMARDs).

    •  

  • Coverage is provided for individuals with active psoriatic arthritis who have not responded sufficiently to nonbiologic therapies. A history of intolerance to conventional systemic therapy may also qualify the patient for coverage.

    •  

  • Humira is approved for patients with moderate to severe Crohn's disease who have not achieved adequate results with traditional therapies, including corticosteroids or immunosuppressants.

    •  

  • In cases of ulcerative colitis, SummaCare covers Humira for individuals who have moderately to severely active forms of the disease that have not responded well to other therapies like corticosteroids.

    •  

  • Patients diagnosed with moderate to severe plaque psoriasis, who are candidates for systemic therapy or phototherapy, and have not obtained adequate results from alternative systemic therapies, are eligible for Humira coverage.

    •  

  • Humira is also available for those with ankylosing spondylitis if the patient has shown an inadequate response to conventional treatments like NSAIDs (non-steroidal anti-inflammatory drugs).

    •  

  • For pediatric patients aged two and older diagnosed with moderate to severe juvenile idiopathic arthritis, Humira coverage is provided if there is a documented failure or intolerance to at least one DMARD.

 

Why SummaCare Might Deny Humira Coverage

 

Situations Where SummaCare Might Deny Humira Coverage

 

  • **Lack of Medical Necessity**: If SummaCare determines that Humira is not medically necessary for the patient's condition, coverage may be denied. This could include cases where alternative treatments are available and deemed sufficient by the insurer.

    •  

  • **Insufficient Documentation**: Claims may be denied if there is insufficient medical documentation provided to justify the need for Humira. Documentation often needs to demonstrate why Humira is required over other treatments.

    •  

  • **Policy Exclusions**: Specific policies may have exclusions that do not cover certain biological medications, including Humira, due to the nature of contract agreements or plan stipulations.

    •  

  • **Non-Compliance with Step Therapy Requirements**: If a member does not comply with step therapy protocols—where they must try and fail on a less expensive medication before proceeding to Humira—coverage can be denied.

    •  

  • **Out-of-Network Provider**: Using a provider or pharmacy that is not within the SummaCare network could result in non-coverage of Humira prescriptions.

    •  

  • **Pre-authorization Not Obtained**: Claims for Humira may be denied if pre-authorization requirements are not met, meaning that SummaCare did not give prior approval for the therapy.

    •  

  • **Experimental or Investigational Use**: Coverage may be denied if Humira is being used for an off-label condition that is considered experimental or investigational under SummaCare’s guidelines.

 

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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.

 

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

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 SummaCare

 

Verify Your Plan Coverage

 

  • Contact SummaCare directly by calling the customer service number on your insurance card to confirm if Humira is included in your plan's formulary.

    •  

  • Log into your SummaCare member account online to access your plan details and review the formulary list yourself.

 

Consult Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Humira and obtain any necessary documentation, such as a prescription or prior authorization.

    •  

  • Ensure your healthcare provider knows your plan specifics to provide any required information to SummaCare for coverage approval.

 

Obtain Prior Authorization

 

  • Work with your healthcare provider to complete and submit any required prior authorization forms to SummaCare. This step is crucial as Humira is often a medication that requires this pre-approval.

    •  

  • Follow up with your healthcare provider or SummaCare to ensure the prior authorization process is complete and approved.

 

Explore Financial Assistance Programs

 

  • Ask your healthcare provider about any pharmaceutical assistance programs offered by the manufacturer of Humira for additional support if coverage challenges arise.

    •  

  • Visit the official Humira website or contact their support line to inquire about patient assistance programs that might subsidize your medication costs.

 

Fill Your Prescription

 

  • Once SummaCare approves your Humira coverage, take your prescription to an in-network pharmacy preferred by SummaCare or use their mail-order service if available.

    •  

  • Verify with the pharmacy that your coverage is applied correctly during the filling process to avoid unexpected costs.

 

Regularly Review and Renew Authorization

 

  • Check if your coverage or authorization requires renewal periodically, and proactively initiate renewal processes to avoid lapses in your Humira therapy.

    •  

  • Stay updated with any changes in SummaCare's formulary or coverage policies that might affect your Humira coverage.

 

Reach Out for Support

 

  • Contact SummaCare's customer service or a dedicated care coordinator for any assistance in navigating the coverage process or addressing any issues.

    •  

  • Seek advice from patient advocacy groups or resources specializing in insurance issues for additional guidance.

 

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Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

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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.

 

Have questions left?

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A weight management program tailored to you

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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Curex provides allergy care plans for allergies, asthma, eczema and pet allergies.

Curex providers may prescribe sublingual allergy drops that contain the same ingredients as allergy shots but are more convenient & affordable.
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Curex-affiliated medical practices are independently owned and operated by licensed physicians who provide services using the Curex telehealth platform.

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