Does Tufts Health Plan Cover Humira

Explore Humira coverage under Tufts Health Plan, costs without insurance, denial reasons, and steps to secure coverage in this comprehensive guide.
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Coverage of Humira by Tufts Health Plan

 

  • Tufts Health Plan covers Humira for a variety of conditions including rheumatoid arthritis, Crohn's disease, and psoriasis, among others.
  •  

  • Coverage typically requires prior authorization to confirm medical necessity based on the patient's specific diagnosis and treatment history.
  •  

  • Patients must often try and fail less expensive treatment options before Humira is approved, following the "step therapy" protocol.
  •  

  • Approval for coverage might require documentation from healthcare providers outlining the necessity of Humira due to the inadequacy of other treatments.
  •  

  • Specialty pharmacy requirements often apply, meaning Humira must be obtained through designated pharmacies to be covered under the plan.

 

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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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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 Tufts Health Plan

 

Initial Contact with Tufts Health Plan

 

  • Visit the official Tufts Health Plan website to gather information about your specific health plan and see if Humira is listed as a covered medication.
  •  

  • Contact Tufts Health Plan customer service through the phone number provided on your insurance card to ask about Humira coverage specifics.
  •  

  • Make sure to have your insurance ID number handy, as well as details regarding the prescription for Humira from your healthcare provider.

 

Obtain Prior Authorization

 

  • Ask your healthcare provider if they can assist in obtaining a prior authorization from Tufts Health Plan, as this is often required for specialty medications like Humira.
  •  

  • Ensure your doctor provides all necessary medical records and justification showing the need for Humira to Tufts Health Plan during the prior authorization process.
  •  

  • Follow up with both Tufts Health Plan and your healthcare provider to confirm that the prior authorization request is being processed promptly.

 

Consider Step Therapy Requirements

 

  • Be prepared to supply information on any alternative medications you have tried, as Tufts Health Plan may require evidence of other treatments before approving Humira.
  •  

  • Your healthcare provider should document the effectiveness or lack of response to previous medications, if applicable.

 

Monitor for Coverage Determination

 

  • Wait for a coverage determination from Tufts Health Plan after submitting the prior authorization request, which can take a few days to a few weeks.
  •  

  • If there is any delay, contact Tufts Health Plan to ask for an update and potential reasons for hold-ups.

 

Review the Outcome

 

  • If approved, confirm details such as how often Humira can be refilled and the cost that will be covered vs. your out-of-pocket expense.
  •  

  • If denied, request detailed reasoning for the denial from Tufts Health Plan and inquire about the appeals process.

 

Appeals Process

 

  • If needed, file an appeal with Tufts Health Plan by providing any additional documentation and letters of medical necessity from your healthcare provider.
  •  

  • Stay in touch with your healthcare provider to ensure all additional information needed for an effective appeal is submitted in a timely manner.

 

Ongoing Coordination

 

  • Once approved, work with your pharmacy to confirm that they can process your prescription through Tufts Health Plan.
  •  

  • Continue to monitor your Humira coverage terms, as plan details can change annually or with different enrollment periods.

 

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FAQs

Does Tufts Health Plan Cover Humira

Explore Humira coverage under Tufts Health Plan, costs without insurance, denial reasons, and steps to secure coverage in this comprehensive guide.
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Is Humira Covered by Tufts Health Plan

 

Coverage of Humira by Tufts Health Plan

 

  • Tufts Health Plan covers Humira for a variety of conditions including rheumatoid arthritis, Crohn's disease, and psoriasis, among others.
  •  

  • Coverage typically requires prior authorization to confirm medical necessity based on the patient's specific diagnosis and treatment history.
  •  

  • Patients must often try and fail less expensive treatment options before Humira is approved, following the "step therapy" protocol.
  •  

  • Approval for coverage might require documentation from healthcare providers outlining the necessity of Humira due to the inadequacy of other treatments.
  •  

  • Specialty pharmacy requirements often apply, meaning Humira must be obtained through designated pharmacies to be covered under the plan.

 

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Tufts Health Plan's Approved Criteria for Humira Coverage

 

General Criteria for Humira Coverage

 

  • Humira may be covered for members who have been diagnosed with specific chronic inflammatory conditions. These conditions can include rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, Crohn's disease, ulcerative colitis, and plaque psoriasis.
  •  

  • Coverage is generally provided for members who have not responded adequately to conventional therapies or require initiation of a biologic treatment based on clinical evaluation.

 

Specific Conditions for Coverage

 

  • Rheumatoid Arthritis: Members must have a diagnosis confirmed by a healthcare provider and should have failed to respond to prior disease-modifying antirheumatic drugs (DMARDs) treatments.
  •  

  • Psoriatic Arthritis: Humira may be approved for members with a diagnosis severely impacting quality of life, with insufficient response to oral therapies or non-biologic DMARDs.

 

  • Ankylosing Spondylitis: Coverage typically requires a confirmed diagnosis and trials of NSAIDs have been insufficient in managing symptoms.
  •  

  • Juvenile Idiopathic Arthritis: Consideration is given to children over the age of two with moderate to severe symptoms and intolerant to or failed response to conventional treatments.

 

Crohn’s Disease and Ulcerative Colitis

 

  • For both Crohn’s Disease and Ulcerative Colitis, coverage for Humira is considered when members have moderate to severe symptoms that have not been adequately controlled with other treatment regimens.
  •  

  • A confirmed diagnosis and documentation of disease severity by a healthcare provider are often required.

 

For Plaque Psoriasis

 

  • Coverage for individuals with chronic plaque psoriasis may be granted if they have moderate to severe disease and have not responded to topical, phototherapy, or systemic treatments.
  •  

  • The member should be evaluated and recommended by a dermatologist.

 

Treatment Considerations

 

  • The plan typically requires member participation in a step therapy protocol before Humira is approved, having tried and failed or having a documented contraindication to other drugs or therapies.
  •  

  • Regular assessment of the member’s progress on Humira is generally required, and ongoing coverage may be contingent upon the demonstrable benefit in terms of symptom control and quality of life improvement.

 

Why Tufts Health Plan Might Deny Humira Coverage

 

Reasons for Denial of Humira Coverage by Tufts Health Plan

 

  • **Non-Formulary Medication:** Tufts Health Plan may deny coverage if Humira is not included on the specific formulary applicable to the member's health plan. Prescription drug formularies are defined by the plan and vary by product.
  •  

  • **Lack of Medical Necessity:** If Tufts Health Plan determines that Humira is not medically necessary based on their clinical guidelines or if alternative treatments are deemed appropriate.
  •  

  • **Experimental or Investigational Use:** Humira coverage may be denied if it is being prescribed for a condition or use that is considered experimental or investigational under the Tufts Health Plan criteria.
  •  

  • **Administrative or Clerical Errors:** If there is incorrect information submitted about the patient's health history, diagnosis, or required documentation that does not comply with Tufts Health Plan's prerequisites.
  •  

  • **Absence of Prior Authorization:** Failure to obtain required prior authorization before starting Humira treatment can result in coverage denial. Tufts Health Plan requires prior authorization for many specialty drugs such as Humira.
  •  

  • **Non-Adherence to Step Therapy Requirements:** Denial can occur if the patient has not tried other covered therapies before Humira, according to the plan's step therapy policies and guidelines.
  •  

  • **Prescription Does Not Meet Plan Guidelines:** Coverage may be denied if the prescription for Humira does not align with the plan-specific guidelines, including dosing, frequency, or duration of treatment.
  •  

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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 Tufts Health Plan

 

Initial Contact with Tufts Health Plan

 

  • Visit the official Tufts Health Plan website to gather information about your specific health plan and see if Humira is listed as a covered medication.
  •  

  • Contact Tufts Health Plan customer service through the phone number provided on your insurance card to ask about Humira coverage specifics.
  •  

  • Make sure to have your insurance ID number handy, as well as details regarding the prescription for Humira from your healthcare provider.

 

Obtain Prior Authorization

 

  • Ask your healthcare provider if they can assist in obtaining a prior authorization from Tufts Health Plan, as this is often required for specialty medications like Humira.
  •  

  • Ensure your doctor provides all necessary medical records and justification showing the need for Humira to Tufts Health Plan during the prior authorization process.
  •  

  • Follow up with both Tufts Health Plan and your healthcare provider to confirm that the prior authorization request is being processed promptly.

 

Consider Step Therapy Requirements

 

  • Be prepared to supply information on any alternative medications you have tried, as Tufts Health Plan may require evidence of other treatments before approving Humira.
  •  

  • Your healthcare provider should document the effectiveness or lack of response to previous medications, if applicable.

 

Monitor for Coverage Determination

 

  • Wait for a coverage determination from Tufts Health Plan after submitting the prior authorization request, which can take a few days to a few weeks.
  •  

  • If there is any delay, contact Tufts Health Plan to ask for an update and potential reasons for hold-ups.

 

Review the Outcome

 

  • If approved, confirm details such as how often Humira can be refilled and the cost that will be covered vs. your out-of-pocket expense.
  •  

  • If denied, request detailed reasoning for the denial from Tufts Health Plan and inquire about the appeals process.

 

Appeals Process

 

  • If needed, file an appeal with Tufts Health Plan by providing any additional documentation and letters of medical necessity from your healthcare provider.
  •  

  • Stay in touch with your healthcare provider to ensure all additional information needed for an effective appeal is submitted in a timely manner.

 

Ongoing Coordination

 

  • Once approved, work with your pharmacy to confirm that they can process your prescription through Tufts Health Plan.
  •  

  • Continue to monitor your Humira coverage terms, as plan details can change annually or with different enrollment periods.

 

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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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Titration

We gradually adjust your dosage to reach the optimal therapeutic level, ensuring maximum effectiveness while minimizing potential side effects.

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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 (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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