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Does SummaCare Cover Stelara

Explore SummaCare's coverage for Stelara, reasons for denial, tips for approval, pricing without insurance, and answers to common questions.

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Does SummaCare Cover Stelara

Stelara is covered by SummaCare, typically under specific medical necessity criteria. It's primarily approved for conditions like moderate to severe plaque psoriasis, psoriatic arthritis, and Crohn's disease.

Coverage requires a prior authorization based on your medical history, severity of the condition, and response to previous treatments. Detailed documentation from your healthcare provider can improve the likelihood of approval.

Stelara is generally considered when other therapies have not worked or cannot be used. Criteria include proof of failure or intolerance to standard therapy options.

It's essential to verify plan specifics and network restrictions, which may affect coverage. Contacting SummaCare directly or consulting the member portal can provide the most accurate information.

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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 SummaCare

Verify Your Insurance Coverage

Contact SummaCare customer service to confirm if Stelara is covered under your current plan. Obtain details about coverage limits, copayments, and any necessary pre-authorization.

Check your plan's formulary online if available. The formulary is a list of medications covered by your insurance. Make sure Stelara appears on this list.

Consult With Your Healthcare Provider

Discuss with your healthcare provider the need for Stelara in treating your condition. Ensure they provide proper documentation and a prescription, as this will be necessary for insurance purposes.

Ask your provider if they have experience in obtaining medication coverage with SummaCare and if they can assist with the paperwork or appeal process if needed.

Pre-Authorization and Documentation

Submit a pre-authorization request to SummaCare, if required. This often involves your healthcare provider sending clinical information supporting the necessity of Stelara.

Gather any additional medical records or documents that may support your case for using Stelara, including previous treatments and their outcomes.

Contact SummaCare's Pharmacy Services

Reach out to SummaCare's pharmacy services department for specific guidance on obtaining a drug like Stelara. They may require additional forms or have specific procedures to follow.

Inquire about specialty pharmacy requirements, as Stelara may need to be dispensed through a particular pharmacy network.

Consider Financial Assistance Programs

If coverage is denied or insufficient, explore financial assistance programs offered by the manufacturer of Stelara. They may offer copay assistance or other resources for eligible patients.

Contact patient advocacy groups that focus on your condition for additional resources or advice on navigating insurance challenges.

Appeal a Denied Claim

If your initial claim for Stelara is denied, review the denial letter carefully for specific reasons the claim was not approved.

Work with your healthcare provider to draft an appeal, providing supplementary information that addresses the denial reasons. Include letters of medical necessity and any relevant clinical guidelines supporting the use of Stelara.

Submit the appeal to SummaCare according to their guidelines, and make sure to track all communications for future reference.

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Does SummaCare Cover Stelara

Explore SummaCare's coverage for Stelara, reasons for denial, tips for approval, pricing without insurance, and answers to common questions.

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Is Stelara Covered by SummaCare

Does SummaCare Cover Stelara

Stelara is covered by SummaCare, typically under specific medical necessity criteria. It's primarily approved for conditions like moderate to severe plaque psoriasis, psoriatic arthritis, and Crohn's disease.

Coverage requires a prior authorization based on your medical history, severity of the condition, and response to previous treatments. Detailed documentation from your healthcare provider can improve the likelihood of approval.

Stelara is generally considered when other therapies have not worked or cannot be used. Criteria include proof of failure or intolerance to standard therapy options.

It's essential to verify plan specifics and network restrictions, which may affect coverage. Contacting SummaCare directly or consulting the member portal can provide the most accurate information.

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SummaCare's Approved Criteria for Stelara Coverage

Criteria for Coverage of Stelara under SummaCare

**Diagnosis of Plaque Psoriasis**: Confirmed through detailed clinical evaluation and documented as moderate to severe where other systemic therapies are inadequate or inappropriate.

**Treatment of Active Psoriatic Arthritis**: Approved when there is a rheumatologist-confirmed diagnosis of active psoriatic arthritis with insufficient response to other non-biological DMARDs.

**Crohn’s Disease Coverage**: For adults over 18 years with a gastroenterologist diagnosis of moderate to severe Crohn’s Disease, showing inadequate response or intolerance to corticosteroids or immunosuppressants.

**Ulcerative Colitis**: Prescription is covered for individuals over 18 fitting the moderate to severe category after other therapeutic avenues like corticosteroids or immunomodulators have been utilized considerably or shown intolerance.

**Alternatives Ineffective or Unsafe**: There must be documentation of prior ineffective treatments or contraindications for Stelara to be granted coverage.

**Adjustments for Pediatric Usage**: For children 12 years or older with moderate to severe plaque psoriasis, coverage is available if the standard systemic treatments are unsuitable, as demonstrated by healthcare provider documentation.

Prior Authorization and Approval Process

**Healthcare Provider’s Consent**: Requires documented consent from the prescribing healthcare professional, demonstrating understanding of the therapy and consent to initiate treatment following protocol.

**Comprehensive Medical Records**: Submission of detailed medical history substantiating the necessity of Stelara treatment, including but not limited to laboratory results and physician assessments.

**Periodic Evaluation**: Approval is conditional upon regular reviews showing clinical improvement or continued medical necessity, evidenced by healthcare provider reports each coverage period.

Continued Coverage Requirements

**Documented Improvement**: Continuous approval is contingent on evidence of improvement or stabilization in the condition, as confirmed by healthcare provider assessments and patient progress reports.

**Consistent Follow-up Visits**: Regular follow-up visits must be scheduled to ensure appropriate use and effectiveness of Stelara, as a part of treatment compliance checks.

**Reassessment of Treatment Plan**: Ongoing verification that Stelara remains the best treatment option through periodic reassessments performed by healthcare professionals.

Why SummaCare Might Deny Stelara Coverage

Situations When SummaCare Might Deny Stelara Coverage

Stelara is prescribed for a condition that is not FDA approved for this medication. Off-label uses may not be covered.

The prescribed dosage of Stelara exceeds the recommended limits or frequency as per SummaCare's policy guidelines.

The patient does not meet the specific medical criteria outlined by SummaCare, such as a required failure of prior therapies or absence of necessary diagnostic confirmation.

Lack of documented evidence from the healthcare provider demonstrating the medical necessity of Stelara for the patient's condition.

Stelara is requested but the patient is enrolled under a plan that explicitly excludes coverage for biologic medications.

Failure to comply with SummaCare's prior authorization process, which requires prior approval before the medication is covered.

The prescription does not align with step therapy protocols that require the use of alternative treatments before covering Stelara.

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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 SummaCare

Verify Your Insurance Coverage

Contact SummaCare customer service to confirm if Stelara is covered under your current plan. Obtain details about coverage limits, copayments, and any necessary pre-authorization.

Check your plan's formulary online if available. The formulary is a list of medications covered by your insurance. Make sure Stelara appears on this list.

Consult With Your Healthcare Provider

Discuss with your healthcare provider the need for Stelara in treating your condition. Ensure they provide proper documentation and a prescription, as this will be necessary for insurance purposes.

Ask your provider if they have experience in obtaining medication coverage with SummaCare and if they can assist with the paperwork or appeal process if needed.

Pre-Authorization and Documentation

Submit a pre-authorization request to SummaCare, if required. This often involves your healthcare provider sending clinical information supporting the necessity of Stelara.

Gather any additional medical records or documents that may support your case for using Stelara, including previous treatments and their outcomes.

Contact SummaCare's Pharmacy Services

Reach out to SummaCare's pharmacy services department for specific guidance on obtaining a drug like Stelara. They may require additional forms or have specific procedures to follow.

Inquire about specialty pharmacy requirements, as Stelara may need to be dispensed through a particular pharmacy network.

Consider Financial Assistance Programs

If coverage is denied or insufficient, explore financial assistance programs offered by the manufacturer of Stelara. They may offer copay assistance or other resources for eligible patients.

Contact patient advocacy groups that focus on your condition for additional resources or advice on navigating insurance challenges.

Appeal a Denied Claim

If your initial claim for Stelara is denied, review the denial letter carefully for specific reasons the claim was not approved.

Work with your healthcare provider to draft an appeal, providing supplementary information that addresses the denial reasons. Include letters of medical necessity and any relevant clinical guidelines supporting the use of Stelara.

Submit the appeal to SummaCare according to their guidelines, and make sure to track all communications for future reference.

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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.

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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 SummaCare Cover Stelara

Explore SummaCare's coverage for Stelara, reasons for denial, tips for approval, pricing without insurance, and answers to common questions.

Achieve Your Goals Faster with Curex