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Does Affinity Health Plan Cover Orencia

Explore Orencia coverage with Affinity Health Plan, reasons for denial, cost without insurance, and FAQs in this insightful guide.

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Coverage of Orencia by Affinity Health Plan

Orencia is typically covered by Affinity Health Plan when deemed medically necessary for conditions like rheumatoid arthritis.

Coverage requires a prescription and often prior authorization, meaning your healthcare provider must demonstrate medical necessity.

Patients may need to try other treatments first as part of step therapy requirements before Orencia is approved.

Ensure your plan’s formulary includes Orencia, as drug coverage can differ across specific plans and tiers.

Consult with your healthcare provider and Affinity Health Plan to confirm specific benefits and any associated out-of-pocket costs.

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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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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 Orencia Coverage with Affinity Health Plan

Verify Your Coverage and Benefits with Affinity Health Plan

Check if Orencia (abatacept) is included in your formulary, which is the list of medications covered by your insurance.

Contact customer service to confirm details on coverage for Orencia and any specific requirements or limitations.

Consult with Your Healthcare Provider

Discuss with your doctor or healthcare provider the medical necessity of using Orencia for your condition.

Ensure your provider is aware of Affinity Health Plan's requirements for coverage and can assist in meeting them.

Initiate Pre-Authorization (if required)

If Orencia requires pre-authorization, have your healthcare provider submit a request to Affinity Health Plan.

Provide any necessary documentation, such as medical records or a letter of medical necessity, to support the authorization request.

Check for Specialty Pharmacy Requirements

Determine if Affinity Health Plan requires Orencia to be obtained through a specialty pharmacy.

If so, coordinate with the designated specialty pharmacy for the dispensing and delivery of Orencia.

Explore Financial Assistance Programs

Research available patient assistance programs or manufacturer coupons that may help reduce the cost of Orencia.

Coordinate with your healthcare provider or pharmacy to apply for any applicable financial assistance options.

Follow-Up with Affinity Health Plan

After submission of a pre-authorization request, follow up with Affinity Health Plan to confirm receipt and review status.

If there are any issues or denials, work with your healthcare provider to address them promptly.

Renew Continuous Coverage

Remember to renew any necessary approvals or authorizations prior to expiration to avoid interruptions in your Orencia treatment.

Stay updated with any changes in your plan’s formulary or eligibility criteria.

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FAQs

Does Affinity Health Plan Cover Orencia

Explore Orencia coverage with Affinity Health Plan, reasons for denial, cost without insurance, and FAQs in this insightful guide.

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Is Orencia Covered by Affinity Health Plan

Coverage of Orencia by Affinity Health Plan

Orencia is typically covered by Affinity Health Plan when deemed medically necessary for conditions like rheumatoid arthritis.

Coverage requires a prescription and often prior authorization, meaning your healthcare provider must demonstrate medical necessity.

Patients may need to try other treatments first as part of step therapy requirements before Orencia is approved.

Ensure your plan’s formulary includes Orencia, as drug coverage can differ across specific plans and tiers.

Consult with your healthcare provider and Affinity Health Plan to confirm specific benefits and any associated out-of-pocket costs.

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Affinity Health Plan's Approved Criteria for Orencia Coverage

Eligibility Criteria for Orencia Coverage

Patients must have a confirmed diagnosis of rheumatoid arthritis, juvenile idiopathic arthritis, or psoriatic arthritis verified by a rheumatologist or relevant specialist.

Treatment with Orencia must be deemed medically necessary, with evidence of active disease despite standard therapeutic measures, including disease-modifying antirheumatic drugs (DMARDs).

Documentation of patient history showing inadequate response or intolerance to at least one TNF inhibitor is required before considering Orencia treatment as a covered option.

The healthcare provider must submit evidence supporting the rationale for using Orencia, outlining previous treatment history and a clear plan for ongoing monitoring and evaluation of the patient's response to therapy.

Prior authorization requests must include a detailed patient profile with supportive clinical data illustrating the need for Orencia based on current clinical guidelines and standards of care.

Dosage and Administration Requirements

Coverage is provided when Orencia is administered according to FDA-approved dosing guidelines, which require adjustments based on patient weight and disease severity.

Initial Orencia infusion should be conducted in a healthcare facility under the supervision of a qualified healthcare professional to assess initial tolerance and response.

Home administration may be approved following the initial supervision period, given the patient's stability and capability to self-administer or have access to reliable caregiver support.

Regular follow-up appointments must be documented to ensure clinical efficacy and safety of treatment, with ongoing adjustment as necessary in coordination with the healthcare provider.

Necessary Documentation for Coverage

All applications must include a prescribing physician’s note detailing the medical necessity of Orencia therapy, including specific patient history and expected benefits of treatment.

A complete list of all previous and concurrent medications, including any biological products or other DMARDs previously tried or currently being used, must be submitted.

Detailed clinical notes or reports should accompany the request, including laboratory results, imaging, and other diagnostic information supporting the Orencia use.

Why Affinity Health Plan Might Deny Orencia Coverage

Reasons Affinity Health Plan Might Deny Orencia Coverage

Treatment Not Medically Necessary: Affinity Health Plan may deny coverage if Orencia is not deemed medically necessary for the patient's condition based on their criteria and guidelines.

Non-Compliance with Prescribing Guidelines: If the prescription does not align with the plan's established prescribing guidelines, such as specific dosage requirements or administration methods, coverage may be denied.

No Prior Authorization: Orencia may require prior authorization before it is administered. If prior authorization is not obtained, the plan may refuse to cover the medication.

Use for Non-Approved Indications: Affinity Health Plan may deny coverage if Orencia is used for conditions or indications not approved by the FDA or not listed in the plan's coverage policy.

Experimental or Investigational Use: If Orencia is being used in a manner that is considered experimental or investigational by the plan, it might not be covered.

Incomplete Documentation: Failure to provide necessary medical records or documentation supporting the necessity for Orencia therapy might result in denial of coverage.

Plan Exclusions: Certain health plans may have specific exclusions for biologics like Orencia. If the patient's plan excludes coverage for this medication, it will not be covered.

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How Much Does Orencia Cost without Insurance?

Cost of Orencia Without Insurance

The approximate cost for Orencia, when paying out of pocket without insurance, is between $4,500 to $5,000 per month. This cost can vary based on dosage, form (whether it's an IV infusion or subcutaneous injection), and the pharmacy or healthcare provider dispensing the medication.

Some patients may require different dosages which can further influence the cost, typically leading to higher expenses if more medication is required.

Patients without insurance may be eligible for manufacturer discounts or assistance programs, which can provide significant cost reductions. These programs often have specific eligibility requirements based on income and other factors.

Pharmacy discount cards or online services might offer slightly lower prices than traditional pharmacies.

Comparing costs between pharmacies and considering mail-order options can also help in reducing the overall expense.

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 Orencia Coverage with Affinity Health Plan

Verify Your Coverage and Benefits with Affinity Health Plan

Check if Orencia (abatacept) is included in your formulary, which is the list of medications covered by your insurance.

Contact customer service to confirm details on coverage for Orencia and any specific requirements or limitations.

Consult with Your Healthcare Provider

Discuss with your doctor or healthcare provider the medical necessity of using Orencia for your condition.

Ensure your provider is aware of Affinity Health Plan's requirements for coverage and can assist in meeting them.

Initiate Pre-Authorization (if required)

If Orencia requires pre-authorization, have your healthcare provider submit a request to Affinity Health Plan.

Provide any necessary documentation, such as medical records or a letter of medical necessity, to support the authorization request.

Check for Specialty Pharmacy Requirements

Determine if Affinity Health Plan requires Orencia to be obtained through a specialty pharmacy.

If so, coordinate with the designated specialty pharmacy for the dispensing and delivery of Orencia.

Explore Financial Assistance Programs

Research available patient assistance programs or manufacturer coupons that may help reduce the cost of Orencia.

Coordinate with your healthcare provider or pharmacy to apply for any applicable financial assistance options.

Follow-Up with Affinity Health Plan

After submission of a pre-authorization request, follow up with Affinity Health Plan to confirm receipt and review status.

If there are any issues or denials, work with your healthcare provider to address them promptly.

Renew Continuous Coverage

Remember to renew any necessary approvals or authorizations prior to expiration to avoid interruptions in your Orencia treatment.

Stay updated with any changes in your plan’s formulary or eligibility criteria.

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Orencia FAQ

What are the common side effects of Orencia?

Common Side Effects of Orencia

**Infections:** Increased risk of upper respiratory infections, such as colds or sinus infections.

**Headache:** Mild to moderate headaches are commonly reported.

**Nausea:** Some patients may experience feelings of nausea.

**Fatigue:** Feeling unusually tired or weak can occur as well.

**Cough:** A persistent cough may develop during treatment.

**Pain:** Injection site reactions like redness or discomfort are possible.

How does Orencia work in treating rheumatoid arthritis?

How Orencia Works

Orencia is a biologic medication that targets specific components of the immune system to reduce inflammation in rheumatoid arthritis.

It works by binding to CD80/CD86 receptors on antigen-presenting cells, preventing the activation of T-cells, which play a critical role in the autoimmune response.

By inhibiting T-cell activation, Orencia helps decrease the inflammation and joint damage caused by rheumatoid arthritis.

Orencia is administered through injection, and its efficacy may take several weeks to become noticeable.

Benefits of Orencia

Reduces pain and swelling in affected joints, improving physical function.
Lowers the progression of joint damage over time.
Improves overall quality of life for patients with rheumatoid arthritis.

Is Orencia considered a biologic medication?

Orencia Overview

Orencia (abatacept) is classified as a biologic medication, used primarily to treat autoimmune conditions like rheumatoid arthritis.

Biologic Nature

It is a fusion protein that inhibits T-cell activation, an essential part of the immune response, thereby reducing inflammation.

Mechanism of Action

By blocking the co-stimulatory signal required for full T-cell activation, Orencia helps decrease abnormal immune responses involved in autoimmune diseases.

Administration and Use

Orencia is administered via intravenous infusion or subcutaneous injection, typically in a clinical setting.

Considerations

Patients should discuss potential benefits and risks with a healthcare professional, as Orencia may affect the immune system and increase the risk of infections.

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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. 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 Affinity Health Plan Cover Orencia

Explore Orencia coverage with Affinity Health Plan, reasons for denial, cost without insurance, and FAQs in this insightful guide.

Achieve Your Goals Faster with Curex