Does WellCare Cover Humira

Explore Humira coverage by WellCare, reasons for denial, coverage tips, costs without insurance, and FAQs in our comprehensive guide.
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Coverage Overview

 

  • WellCare commonly covers Humira for approved conditions like rheumatoid arthritis, psoriasis, Crohn’s disease, and ulcerative colitis. Coverage depends on the policy and state regulations.

 

Authorization Requirements

 

  • Pre-authorization might be needed before beginning treatment. This involves the healthcare provider submitting a formal request to WellCare explaining the medical necessity of Humira for the patient's condition.

 

Criteria for Coverage

 

  • Patients typically must demonstrate a lack of response or intolerance to other therapies before Humira is approved. Supporting medical documentation from the healthcare provider is crucial.

 

Cost Considerations

 

  • Costs can include deductibles, co-pays, and co-insurance. It's advised to contact WellCare directly for exact pricing details, considering policy nuances and patient eligibility.

 

Appeal Process

 

  • If initial coverage is denied, there's an appeal process in which a healthcare provider can offer additional information to support the need for Humira.

 

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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 WellCare

 

Understand Your WellCare Plan

 

  • Visit the WellCare website or contact their customer service to gain a comprehensive understanding of your current plan details and benefits. Note down any information specific to prescription drug coverage.
  •  

  • Gather information about the formulary. Confirm if Humira is listed as a covered medication, as not all plans may include it within their formulary list.

 

Consult With Your Healthcare Provider

 

  • Discuss your need for Humira with your healthcare provider. Ensure that they have the proper documentation that reflects your medical necessity for Humira, often required for insurance approvals.
  •  

  • Ask your provider to prepare any necessary documentation, such as a letter of medical necessity, which may be especially vital if Humira is not typically covered under your plan.

 

Contact WellCare for Coverage Details

 

  • Reach out to WellCare's pharmacy benefits department to inquire specifically about Humira coverage under your current plan. Note any specific requirements or restrictions related to Humira coverage.
  •  

  • Request detailed information about any prior authorizations, step therapy, or quantity limits that might apply to Humira prescriptions under your plan.

 

Submit Prior Authorization (if required)

 

  • If a prior authorization is necessary, work with your healthcare provider to complete all required forms. Providers often have experience with these forms and can assist in providing accurate information.
  •  

  • Ensure all supporting documentation, such as medical records and your provider's letter, is included when submitting the prior authorization to WellCare.

 

Follow Up on Authorization

 

  • After submission, diligently follow up with WellCare to ensure your prior authorization is being processed. Keep records of any correspondence, including phone calls and written communication.
  •  

  • Upon approval, verify the terms of your Humira coverage, including any copayments, coinsurance, or other out-of-pocket costs you may be responsible for.

 

Explore Financial Assistance Programs

 

  • Research assistance programs provided by AbbVie, the manufacturer of Humira, which may offer further support or discounts on copayments that WellCare does not cover.
  •  

  • Investigate non-profit organizations that may provide grants or financial assistance for individuals prescribed Humira, particularly if there are gaps in your insurance coverage.

 

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FAQs

Does WellCare Cover Humira

Explore Humira coverage by WellCare, reasons for denial, coverage tips, costs without insurance, and FAQs in our comprehensive guide.
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Is Humira Covered by WellCare

 

Coverage Overview

 

  • WellCare commonly covers Humira for approved conditions like rheumatoid arthritis, psoriasis, Crohn’s disease, and ulcerative colitis. Coverage depends on the policy and state regulations.

 

Authorization Requirements

 

  • Pre-authorization might be needed before beginning treatment. This involves the healthcare provider submitting a formal request to WellCare explaining the medical necessity of Humira for the patient's condition.

 

Criteria for Coverage

 

  • Patients typically must demonstrate a lack of response or intolerance to other therapies before Humira is approved. Supporting medical documentation from the healthcare provider is crucial.

 

Cost Considerations

 

  • Costs can include deductibles, co-pays, and co-insurance. It's advised to contact WellCare directly for exact pricing details, considering policy nuances and patient eligibility.

 

Appeal Process

 

  • If initial coverage is denied, there's an appeal process in which a healthcare provider can offer additional information to support the need for Humira.

 

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WellCare's Approved Criteria for Humira Coverage

 

WellCare Approved Criteria for Humira Coverage

 

  • **Diagnosis Confirmation**: The patient must have a confirmed diagnosis that is FDA-approved for Humira treatment. Conditions typically include rheumatoid arthritis, Crohn's disease, ankylosing spondylitis, ulcerative colitis, and other qualifying autoimmune disorders.
  •  

  • **Clinical Assessment**: There must be a detailed clinical assessment indicating that conventional therapies were unsuccessful, or the patient cannot tolerate them. Documentation from a healthcare provider should support this.
  •  

  • **Age Requirements**: The patient must meet the age requirements specified for Humira treatment. Pediatric use may require additional documentation to support the treatment necessity and appropriate dosing.
  •  

  • **Specialist Consultation**: Treatment initiation should be recommended by a specialist in the relevant field (e.g., a rheumatologist for rheumatoid arthritis) to ensure proper diagnosis and treatment planning.
  •  

  • **Therapy Requirement**: The patient should have tried and failed or have contraindications to at least one other form of disease-modifying therapy before transitioning to Humira.
  •  

  • **Dosage and Administration**: Coverage is for the approved dosing and administration route as per Humira’s prescribing information. The need for maintenance doses must also be documented in the medical records.
  •  

  • **Treatment Response Monitoring**: There must be an established plan for monitoring treatment progress and response to Humira. Regular follow-ups with the healthcare provider are required to continue coverage.
  •  

  • **Authorization Process**: Prior authorization is needed. This includes providing the necessary medical records and documentation supporting the need for Humira treatment as per WellCare's guidelines.

 

Why WellCare Might Deny Humira Coverage

 

Reasons for Denial of Humira Coverage by WellCare

 

  • Humira is prescribed for an off-label use that has not been approved by the FDA or does not align with WellCare's covered indications.
  •  

  • The patient does not meet the specific medical criteria in terms of severity or stage of the condition as outlined by WellCare's policy.
  •  

  • Lack of documented evidence that alternative, more cost-effective treatments have been tried and have failed or are contraindicated for the patient.
  •  

  • The prescription is not filled and managed by a specialty pharmacy that is part of WellCare's network.
  •  

  • Required pre-authorization paperwork is incomplete or has not been submitted accurately, leading to administrative denial.
  •  

  • The patient is not eligible due to policy limitations, such as exclusion clauses within their specific WellCare insurance plan.
  •  

  • Renewal requests may be denied if there is insufficient evidence of ongoing benefit from the treatment or if necessary follow-up and reporting requirements are not met.

 

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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 WellCare

 

Understand Your WellCare Plan

 

  • Visit the WellCare website or contact their customer service to gain a comprehensive understanding of your current plan details and benefits. Note down any information specific to prescription drug coverage.
  •  

  • Gather information about the formulary. Confirm if Humira is listed as a covered medication, as not all plans may include it within their formulary list.

 

Consult With Your Healthcare Provider

 

  • Discuss your need for Humira with your healthcare provider. Ensure that they have the proper documentation that reflects your medical necessity for Humira, often required for insurance approvals.
  •  

  • Ask your provider to prepare any necessary documentation, such as a letter of medical necessity, which may be especially vital if Humira is not typically covered under your plan.

 

Contact WellCare for Coverage Details

 

  • Reach out to WellCare's pharmacy benefits department to inquire specifically about Humira coverage under your current plan. Note any specific requirements or restrictions related to Humira coverage.
  •  

  • Request detailed information about any prior authorizations, step therapy, or quantity limits that might apply to Humira prescriptions under your plan.

 

Submit Prior Authorization (if required)

 

  • If a prior authorization is necessary, work with your healthcare provider to complete all required forms. Providers often have experience with these forms and can assist in providing accurate information.
  •  

  • Ensure all supporting documentation, such as medical records and your provider's letter, is included when submitting the prior authorization to WellCare.

 

Follow Up on Authorization

 

  • After submission, diligently follow up with WellCare to ensure your prior authorization is being processed. Keep records of any correspondence, including phone calls and written communication.
  •  

  • Upon approval, verify the terms of your Humira coverage, including any copayments, coinsurance, or other out-of-pocket costs you may be responsible for.

 

Explore Financial Assistance Programs

 

  • Research assistance programs provided by AbbVie, the manufacturer of Humira, which may offer further support or discounts on copayments that WellCare does not cover.
  •  

  • Investigate non-profit organizations that may provide grants or financial assistance for individuals prescribed Humira, particularly if there are gaps in your insurance coverage.

 

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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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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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