Does Blue Cross Blue Shield Cover Enbrel

Explore Blue Cross Blue Shield coverage for Enbrel, reasons for denial, how to secure approval, costs without insurance, and FAQs.
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Does Blue Cross Blue Shield Cover Enbrel?

 

  • Coverage for Enbrel, a medication used to treat autoimmune conditions, often depends on the specific Blue Cross Blue Shield (BCBS) plan. Generally, Enbrel is covered under most BCBS plans under the prescription drug benefit.
  •  

  • Most BCBS plans require prior authorization. This means your healthcare provider must demonstrate medical necessity based on your condition, past treatments, and response to medications.
  •  

  • Typically, coverage is for conditions like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, provided other treatments have been ineffective.
  •  

  • Patients may need to meet particular criteria such as documented diagnosis confirmation and treatment history.
  •  

  • Formulary placement can affect copayments and where you can fill the prescription. It's important to check with BCBS to understand if Enbrel requires using certain pharmacies for better pricing.

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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 Blue Cross Blue Shield

 

Understanding Enbrel Coverage Basics

 

  • Enbrel is a specialty medication often used to treat autoimmune conditions such as rheumatoid arthritis and psoriasis.
  •  

  • Many insurance providers, including Blue Cross Blue Shield (BCBS), may impose specific criteria for coverage, such as prior authorization.

 

Contact Blue Cross Blue Shield

 

  • Call the customer service number found on your BCBS member ID card to confirm the specific plan details regarding Enbrel coverage.
  •  

  • Ask for information about pharmacy benefits, since Enbrel is typically covered under the pharmacy plan rather than medical.

 

Visit Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your treatment plan including the necessity of Enbrel.
  •  

  • Request that your doctor provide the necessary clinical documentation that justifies the need for Enbrel, as this will support your prior authorization.

 

Secure a Prescription

 

  • Ensure your healthcare provider writes you a prescription for Enbrel, which should include the dosage and frequency.
  •  

  • Your provider’s office will typically initiate the prior authorization process required by BCBS for specialty medications like Enbrel.

 

Follow the Prior Authorization Process

 

  • Contact BCBS or have your healthcare provider's office check the requirements for prior authorization for Enbrel.
  •  

  • Gather necessary documentation, which may include the prescription, diagnosis, previous treatments, and rationale for using Enbrel.

 

Submit the Request

 

  • Fill out any required forms provided by your healthcare provider or BCBS for the prior authorization process.
  •  

  • Submit the forms and accompanying documentation through the designated channel (fax, mail, or online portal).

 

Await a Decision

 

  • BCBS will review the submission, which may take several days to a few weeks depending on complexity.
  •  

  • If approved, you will receive confirmation and additional details about how and where to fill your Enbrel prescription.

 

Appeal if Necessary

 

  • If your application is denied, review the explanation provided by BCBS and consult your healthcare provider to strengthen your case.
  •  

  • Follow the appeal process outlined by BCBS, ensuring to provide additional information or documentation as needed.

 

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Individual results vary but some users have reported a noticeable difference in as few as 6-12 months since starting treatments

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FAQs

Does Blue Cross Blue Shield Cover Enbrel

Explore Blue Cross Blue Shield coverage for Enbrel, reasons for denial, how to secure approval, costs without insurance, and FAQs.
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Is Enbrel Covered by Blue Cross Blue Shield

 

Does Blue Cross Blue Shield Cover Enbrel?

 

  • Coverage for Enbrel, a medication used to treat autoimmune conditions, often depends on the specific Blue Cross Blue Shield (BCBS) plan. Generally, Enbrel is covered under most BCBS plans under the prescription drug benefit.
  •  

  • Most BCBS plans require prior authorization. This means your healthcare provider must demonstrate medical necessity based on your condition, past treatments, and response to medications.
  •  

  • Typically, coverage is for conditions like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, provided other treatments have been ineffective.
  •  

  • Patients may need to meet particular criteria such as documented diagnosis confirmation and treatment history.
  •  

  • Formulary placement can affect copayments and where you can fill the prescription. It's important to check with BCBS to understand if Enbrel requires using certain pharmacies for better pricing.

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Blue Cross Blue Shield's Approved Criteria for Enbrel Coverage

 

Criteria for Enbrel Coverage

 

  • Patients must have a diagnosis of one of the following conditions: rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, or plaque psoriasis.
  •  

  • Enbrel may be covered if the patient has tried and failed, or had an inadequate response or intolerance, to at least one disease-modifying anti-rheumatic drug (DMARD), such as methotrexate.
  •  

  • For plaque psoriasis, Enbrel may be covered if the patient has moderate to severe chronic plaque psoriasis and is a candidate for systemic therapy or phototherapy.
  •  

  • For juvenile idiopathic arthritis, coverage applies when the patient is two years of age or older and has failed to respond adequately to at least one other suitable therapy.
  •  

  • Patients must have a prescription for Enbrel from a licensed rheumatologist, dermatologist, or another specialist relevant to their condition.
  •  

  • Documentation of disease severity and prior treatments must be provided to support the medical necessity of Enbrel therapy.
  •  

 

Additional Points

 

  • For continued coverage, documentation of improvement in specific clinical markers or a reduction in disease symptoms after an initial trial period with Enbrel may be required.
  •  

  • Policies may require prior authorization before the commencement of Enbrel therapy to ensure all criteria are met.
  •  

 

Why Blue Cross Blue Shield Might Deny Enbrel Coverage

 

Reasons for Denial of Enbrel Coverage by Blue Cross Blue Shield

 

  • **Non-FDA Approved Uses**: Enbrel may not be covered for off-label uses that are not approved by the FDA or not recognized by BCBS's policy guidelines.
  •  

  • **Lack of Medical Necessity**: If Enbrel is deemed not medically necessary based on BCBS's criteria, coverage may be denied. This includes cases where alternative, less expensive treatments may be available and adequate.
  •  

  • **Policy Exclusions**: Some BCBS policies specifically exclude certain types of treatment or medications, including biologics like Enbrel, if they do not meet established guidelines.
  •  

  • **No Prior Authorization**: Enbrel may require prior authorization, and failure to obtain this before starting treatment can lead to coverage denial.
  •  

  • **Non-Compliance with Treatment Guidelines**: If the prescription of Enbrel is not aligned with current treatment guidelines or Best Practice standards as per BCBS's clinical criteria, the claim may be denied.
  •  

  • **Patient Ineligibility**: Coverage can be denied if the patient does not meet the specified criteria for Enbrel treatment, such as failing to meet conditions related to age, diagnosis, or previous treatment attempts.
  •  

 

Together with our partners we have changed the lives of over 300,000 patients.

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 Blue Cross Blue Shield

 

Understanding Enbrel Coverage Basics

 

  • Enbrel is a specialty medication often used to treat autoimmune conditions such as rheumatoid arthritis and psoriasis.
  •  

  • Many insurance providers, including Blue Cross Blue Shield (BCBS), may impose specific criteria for coverage, such as prior authorization.

 

Contact Blue Cross Blue Shield

 

  • Call the customer service number found on your BCBS member ID card to confirm the specific plan details regarding Enbrel coverage.
  •  

  • Ask for information about pharmacy benefits, since Enbrel is typically covered under the pharmacy plan rather than medical.

 

Visit Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your treatment plan including the necessity of Enbrel.
  •  

  • Request that your doctor provide the necessary clinical documentation that justifies the need for Enbrel, as this will support your prior authorization.

 

Secure a Prescription

 

  • Ensure your healthcare provider writes you a prescription for Enbrel, which should include the dosage and frequency.
  •  

  • Your provider’s office will typically initiate the prior authorization process required by BCBS for specialty medications like Enbrel.

 

Follow the Prior Authorization Process

 

  • Contact BCBS or have your healthcare provider's office check the requirements for prior authorization for Enbrel.
  •  

  • Gather necessary documentation, which may include the prescription, diagnosis, previous treatments, and rationale for using Enbrel.

 

Submit the Request

 

  • Fill out any required forms provided by your healthcare provider or BCBS for the prior authorization process.
  •  

  • Submit the forms and accompanying documentation through the designated channel (fax, mail, or online portal).

 

Await a Decision

 

  • BCBS will review the submission, which may take several days to a few weeks depending on complexity.
  •  

  • If approved, you will receive confirmation and additional details about how and where to fill your Enbrel prescription.

 

Appeal if Necessary

 

  • If your application is denied, review the explanation provided by BCBS and consult your healthcare provider to strengthen your case.
  •  

  • Follow the appeal process outlined by BCBS, ensuring to provide additional information or documentation as needed.

 

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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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