Does Affinity Health Plan Cover Enbrel

Discover if Affinity Health Plan covers Enbrel, reasons for denial, steps to get coverage, costs without insurance, and FAQs in this comprehensive guide.
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Enbrel Coverage by Affinity Health Plan

 

  • Affinity Health Plan may cover Enbrel for conditions such as rheumatoid arthritis, psoriasis, and other qualifying chronic inflammatory diseases.
  •  

  • Coverage is generally determined on a case-by-case basis, following the plan's specific criteria for medical necessity.
  •  

  • Pre-authorization is often required, which means your healthcare provider must demonstrate the necessity of Enbrel based on your individual health condition.
  •  

  • Patients may need to have tried and failed other therapies before Enbrel coverage is approved.
  •  

  • Check your specific plan document or contact member services for detailed information about coverage limitations, co-pays, and provider networks.
  •  

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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 Enbrel Coverage with Affinity Health Plan

 

Research Your Coverage Options

 

  • Visit the Affinity Health Plan website to review the details about prescription coverage and any specific forms you may need for drug approvals.
  •  

  • Consult the Affinity Health Plan formulary list to see if Enbrel is included and under what tier, if applicable. Look for any requirements like prior authorization or step therapy.

 

Consult Your Healthcare Provider

 

  • Talk to your doctor about prescribing Enbrel. Ensure that your healthcare provider is familiar with the specific medical criteria and documentation required by Affinity Health Plan for coverage approval.
  •  

  • Ask your healthcare provider to include detailed medical necessity documentation with the prescription if required by the insurance plan.

 

Contact Affinity Health Plan

 

  • Call the customer service number found on your insurance card to discuss Enbrel coverage specifics. Confirm if Enbrel requires prior authorization or additional medical documentation.
  •  

  • Request detailed information on the process and any forms necessary for submitting a prior authorization request for Enbrel.

 

Gather Necessary Documentation

 

  • Collect any required medical records, treatment history, and written statements from your healthcare provider that demonstrate the necessity of Enbrel for your condition.
  •  

  • Prepare a copy of the prescription from your healthcare provider, ensuring it includes appropriate dosage and frequency details.

 

Submit a Prior Authorization Request

 

  • Complete the prior authorization form as per the instructions provided by Affinity Health Plan. Attach any necessary documentation and your healthcare provider's notes.
  •  

  • Submit the completed prior authorization request and accompanying documents to the designated contact method provided by Affinity Health Plan.

 

Follow Up with Affinity Health Plan

 

  • Contact Affinity Health Plan to confirm receipt of your prior authorization request and ask about the expected time frame for a decision.
  •  

  • If additional information is requested, respond promptly to ensure consideration is not delayed.

 

Receive Notification of Coverage Decision

 

  • Check your mail or online account for official documentation from Affinity Health Plan regarding their decision on your Enbrel coverage request.
  •  

  • If approved, review the details regarding copays, coinsurance, or any other cost-sharing requirements.

 

Appeal if Necessary

 

  • If your request is denied, review the reasons provided and gather any additional supporting information that may help your case.
  •  

  • Follow the appeal process outlined in the denial notice from Affinity Health Plan. Ensure you meet any deadlines for submissions.

 

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FAQs

Does Affinity Health Plan Cover Enbrel

Discover if Affinity Health Plan covers Enbrel, reasons for denial, steps to get coverage, costs without insurance, and FAQs in this comprehensive guide.
Curex allergy drops unboxing

Is Enbrel Covered by Affinity Health Plan

 

Enbrel Coverage by Affinity Health Plan

 

  • Affinity Health Plan may cover Enbrel for conditions such as rheumatoid arthritis, psoriasis, and other qualifying chronic inflammatory diseases.
  •  

  • Coverage is generally determined on a case-by-case basis, following the plan's specific criteria for medical necessity.
  •  

  • Pre-authorization is often required, which means your healthcare provider must demonstrate the necessity of Enbrel based on your individual health condition.
  •  

  • Patients may need to have tried and failed other therapies before Enbrel coverage is approved.
  •  

  • Check your specific plan document or contact member services for detailed information about coverage limitations, co-pays, and provider networks.
  •  

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Affinity Health Plan's Approved Criteria for Enbrel Coverage

 

Eligibility for Enbrel Coverage

 

  • Enbrel is considered for patients diagnosed with moderate to severe rheumatoid arthritis who have failed previous disease-modifying antirheumatic drugs (DMARDs).
  •  

  • Coverage is provided for patients with psoriatic arthritis exhibiting an inadequate response to conventional therapies, including NSAIDs and/or DMARDs.
  •  

  • Patients diagnosed with ankylosing spondylitis who demonstrate a lack of response to NSAIDs are eligible for Enbrel coverage.
  •  

  • In cases of moderate to severe plaque psoriasis, Enbrel is approved when patients have not responded adequately to topical therapies and phototherapy.

 

Required Documentation

 

  • A detailed medical history outlining past treatments and responses is required.
  •  

  • Documentation must include previous attempts with DMARDs or NSAIDs, if applicable.
  •  

  • A formal diagnosis report from a certified healthcare provider is necessary.

 

Provider Specifications

 

  • Requests for Enbrel coverage must be submitted by a licensed rheumatologist, dermatologist, or other certified specialist managing the respective condition.
  •  

  • All prescribers must include a treatment plan that outlines the intended therapy duration and monitoring strategy.

 

Renewal Criteria

 

  • Continued Enbrel coverage requires documentation of clinical improvement or stability of the condition.
  •  

  • Annual submissions of treatment effectiveness reviews and adjustment plans are necessary for ongoing approval.

 

Additional Considerations

 

  • Affinity Health Plan considers patient adherence to prescribed treatments a vital component of ongoing coverage decisions.
  •  

  • A multidisciplinary approach involving coordination between primary care providers and specialists is encouraged to maintain seamless care management.

 

Why Affinity Health Plan Might Deny Enbrel Coverage

 

Non-Medically Necessary Conditions

 

  • Coverage for Enbrel is denied when the treatment is deemed not medically necessary based on medical guidelines or lack of supporting evidence for its necessity.

 

Experimental or Investigational Use

 

  • Enbrel is not covered if it is being used for off-label indications that are considered experimental or investigational, as these uses have not been adequately proven to be effective.

 

Failure to Meet Prior Authorization Requirements

 

  • Enbrel is denied if the prescribing physician has not completed the necessary prior authorization process, which includes providing documentation supporting the diagnosis and treatment plan.

 

Non-Compliance with Formulary Guidelines

 

  • Coverage is not provided if Enbrel is not part of Affinity Health Plan's approved drug formulary and no exception has been granted after a formulary exception request.

 

Absence of Step Therapy Completion

 

  • Enbrel may be denied if a patient has not tried and failed alternative treatments as required by the plan’s step therapy protocols.

 

Out-of-Network Prescription Source

 

  • If Enbrel is obtained from a non-authorized pharmacy or medical provider outside of the network, coverage may be denied.

 

Non-Covered Locations and Facilities

 

  • Enbrel is not covered if administered in locations or facilities that are not approved under the plan, such as certain outpatient settings or non-covered home health care providers.

 

Lack of Appropriate Diagnosis

 

  • Coverage is denied if the diagnosis provided does not align with the approved indications for Enbrel, as recognized by Affinity Health Plan’s policies.

 

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How Much Does Enbrel Cost without Insurance?

 

Approximate Cost of Enbrel Without Insurance

 

  • The approximate cost of Enbrel, an injection used to treat autoimmune conditions such as rheumatoid arthritis and psoriasis, is generally around $5,000 to $7,000 per month without insurance.
  •  

  • This monthly cost can vary depending on the dosage prescribed and the specific pharmacy location.
  •  

  • Patients may be able to find some cost reduction through manufacturer discounts or assistance programs, but these are typically separate from traditional insurance coverage.
  •  

  • Comparing pharmacy prices through services or websites that provide drug price comparisons may help in finding the lowest available price.

 

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 Enbrel Coverage with Affinity Health Plan

 

Research Your Coverage Options

 

  • Visit the Affinity Health Plan website to review the details about prescription coverage and any specific forms you may need for drug approvals.
  •  

  • Consult the Affinity Health Plan formulary list to see if Enbrel is included and under what tier, if applicable. Look for any requirements like prior authorization or step therapy.

 

Consult Your Healthcare Provider

 

  • Talk to your doctor about prescribing Enbrel. Ensure that your healthcare provider is familiar with the specific medical criteria and documentation required by Affinity Health Plan for coverage approval.
  •  

  • Ask your healthcare provider to include detailed medical necessity documentation with the prescription if required by the insurance plan.

 

Contact Affinity Health Plan

 

  • Call the customer service number found on your insurance card to discuss Enbrel coverage specifics. Confirm if Enbrel requires prior authorization or additional medical documentation.
  •  

  • Request detailed information on the process and any forms necessary for submitting a prior authorization request for Enbrel.

 

Gather Necessary Documentation

 

  • Collect any required medical records, treatment history, and written statements from your healthcare provider that demonstrate the necessity of Enbrel for your condition.
  •  

  • Prepare a copy of the prescription from your healthcare provider, ensuring it includes appropriate dosage and frequency details.

 

Submit a Prior Authorization Request

 

  • Complete the prior authorization form as per the instructions provided by Affinity Health Plan. Attach any necessary documentation and your healthcare provider's notes.
  •  

  • Submit the completed prior authorization request and accompanying documents to the designated contact method provided by Affinity Health Plan.

 

Follow Up with Affinity Health Plan

 

  • Contact Affinity Health Plan to confirm receipt of your prior authorization request and ask about the expected time frame for a decision.
  •  

  • If additional information is requested, respond promptly to ensure consideration is not delayed.

 

Receive Notification of Coverage Decision

 

  • Check your mail or online account for official documentation from Affinity Health Plan regarding their decision on your Enbrel coverage request.
  •  

  • If approved, review the details regarding copays, coinsurance, or any other cost-sharing requirements.

 

Appeal if Necessary

 

  • If your request is denied, review the reasons provided and gather any additional supporting information that may help your case.
  •  

  • Follow the appeal process outlined in the denial notice from Affinity Health Plan. Ensure you meet any deadlines for submissions.

 

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Enbrel FAQ

What conditions does Enbrel treat?

 

Conditions Treated by Enbrel

 

  • Rheumatoid Arthritis: Enbrel is commonly used for treating moderate to severe rheumatoid arthritis in adults, helping to reduce joint pain and swelling.
  • Juvenile Idiopathic Arthritis: Effective for kids aged 2 and older, Enbrel helps manage symptoms of juvenile idiopathic arthritis.
  • Psoriatic Arthritis: Patients with psoriatic arthritis can benefit from Enbrel, as it alleviates joint and skin symptoms.
  • Ankylosing Spondylitis: It aids in managing stiffness and inflammation linked to ankylosing spondylitis.
  • Plaque Psoriasis: Enbrel is used for treating moderate to severe plaque psoriasis in adult patients, reducing skin lesions.

 

What are common side effects of Enbrel?

 

Common Side Effects of Enbrel

 

  • Injection Site Reactions: Pain, redness, and swelling at the injection site are quite common.
  •  

  • Infections: Users may experience an increased risk of infections, including upper respiratory tract infections.
  •  

  • Headache: Some patients report headaches following administration.
  •  

  • Nausea and Vomiting: These gastrointestinal issues can occur.
  •  

  • Rash: Skin reactions such as rashes are noted in some individuals.
  •  

  • Heartburn: Stomach discomfort and heartburn are possible.

 

Be sure to consult your healthcare provider for any concerning symptoms or persistent side effects.

How is Enbrel administered?

 

Administration of Enbrel

 

  • Enbrel is administered via subcutaneous injection.
  • It is typically provided in a prefilled syringe, autoinjector (SureClick), or a vial requiring reconstitution.
  • Injections are usually administered on the thigh, abdomen, or outer area of the upper arm.
  • It's crucial to rotate the injection sites to avoid irritation.

 

Preparation and Injection

 

  • Check the solution for particles or discoloration before use.
  • If needed, allow the solution to reach room temperature for about 15–30 minutes.
  • Wash your hands thoroughly before handling the medication.
  • Use an alcohol swab to clean the injection site.
  • Inject Enbrel by angling the needle at 90 degrees for optimal delivery.

 

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Initial Dosage

Your initial medication and dosage are carefully determined by doctors, taking into account your unique health profile. This ensures a personalized and safe treatment plan tailored to your specific needs.

Titration

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

Additional Treatments

Our providers may also recommend medications such as metformin or supplements such as vitamin B12. We recognize the importance of managing side effects, so your care plan may include medication to alleviate them.

Got questions? We have answers.

Do your plans include prescriptions and medications?

Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you. Our service includes continuous support and regular follow-ups to ensure your treatment stays on track.

Our clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance.

Please note: Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.

What medications do your providers prescribe?

We prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide (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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