Does Blue Cross Blue Shield of Illinois Cover Enbrel

Explore Enbrel coverage by Blue Cross Blue Shield of Illinois, reasons for denial, tips to secure coverage, cost without insurance, and key FAQs.
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Coverage Situations for Enbrel

 

  • Blue Cross Blue Shield of Illinois (BCBSIL) typically covers Enbrel for conditions like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis when deemed medically necessary.
  • Coverage often depends on meeting specific medical criteria and obtaining prior authorization.

 

Basic Rules for Getting Enbrel Covered

 

  • Patients must be diagnosed with an approved condition and have documentation from a healthcare professional.
  • Failure of, or contraindication to, other treatments may be required before approval.
  • A healthcare provider may have to submit clinical notes and detailed patient history.
  • Receiving prior authorization from BCBSIL is crucial to ensure the medication is covered under the health 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.

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.

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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 Enbrel Coverage with Blue Cross Blue Shield of Illinois

 

Contact Blue Cross Blue Shield of Illinois

 

  • Reach out to Blue Cross Blue Shield of Illinois (BCBSIL) by calling the customer service number provided on your insurance card. Ask for specific information regarding coverage criteria and procedures for Enbrel.
  •  

  • Visit the BCBSIL official website to review their formulary and see if Enbrel is listed as a covered medication.

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider about your need for Enbrel and ensure that it is medically necessary for your condition. Your doctor may need to provide documentation or a letter of medical necessity to the insurance company.
  •  

  • Have your healthcare provider check if there are any specific forms or additional information required by BCBSIL to facilitate the approval process for Enbrel.

 

Check Your Insurance Plan Details

 

  • Log into your BCBSIL account online to review your benefits and coverage specific to prescription drugs. Look for information on specialty drugs and biologics, as Enbrel may fall under this category.
  •  

  • Understand any possible out-of-pocket costs, such as copays or deductibles related to obtaining Enbrel, and check if there are specific network pharmacies or mail-order options for specialty drugs.

 

Prior Authorization Process

 

  • Determine if Enbrel requires prior authorization by contacting BCBSIL or reviewing your plan’s policy. If required, your healthcare provider will need to submit a prior authorization request.
  •  

  • Ensure all necessary paperwork is accurately completed and submitted. This may include medical records and a treatment history.

 

Follow Up on Authorization

 

  • After submitting the prior authorization, follow up with BCBSIL and your healthcare provider to monitor the status of the request.
  •  

  • If approved, you will receive information on how to proceed with obtaining Enbrel. If denied, review the reasons and explore options for appeal if necessary.

 

Fill Your Prescription

 

  • Once approved, fill your prescription for Enbrel at an in-network pharmacy or through a specialty pharmacy if required by your plan.
  •  

  • Verify the details with the pharmacy regarding copayment amounts and the process for refills, to ensure smooth continuity of your treatment.

 

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FAQs

Does Blue Cross Blue Shield of Illinois Cover Enbrel

Explore Enbrel coverage by Blue Cross Blue Shield of Illinois, reasons for denial, tips to secure coverage, cost without insurance, and key FAQs.
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Is Enbrel Covered by Blue Cross Blue Shield of Illinois

 

Coverage Situations for Enbrel

 

  • Blue Cross Blue Shield of Illinois (BCBSIL) typically covers Enbrel for conditions like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis when deemed medically necessary.
  • Coverage often depends on meeting specific medical criteria and obtaining prior authorization.

 

Basic Rules for Getting Enbrel Covered

 

  • Patients must be diagnosed with an approved condition and have documentation from a healthcare professional.
  • Failure of, or contraindication to, other treatments may be required before approval.
  • A healthcare provider may have to submit clinical notes and detailed patient history.
  • Receiving prior authorization from BCBSIL is crucial to ensure the medication is covered under the health plan.

 

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Blue Cross Blue Shield of Illinois's Approved Criteria for Enbrel Coverage

 

Approved Criteria for Enbrel Coverage

 

  • **Diagnosis:** Enbrel is covered for individuals diagnosed with moderate-to-severe rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, plaque psoriasis, or juvenile idiopathic arthritis.
  •  

  • **Prescription Requirements:** The prescription must be provided by a qualified healthcare professional within the Blue Cross Blue Shield of Illinois network.
  •  

  • **Medical Necessity:** Demonstration of medical necessity is critical. The prescribing physician should provide documentation of the adequacy of the diagnosis, previous treatments attempted, and the clinical rationale for requesting Enbrel as a treatment option.
  •  

  • **Step Therapy Protocols:** Patients may need to demonstrate they have tried and failed less costly treatment options, unless contraindicated or not tolerated. Documentation of such attempts must be provided.
  •  

  • **Age Restrictions:** Pediatric patients must meet specific age requirements, often necessitating a diagnosis of juvenile idiopathic arthritis for ages two years and above.
  •  

  • **Regular Monitoring:** Assurance of regular follow-up and monitoring by the prescribing physician to adapt and oversee the treatment plan effectively.
  •  

 

Why Blue Cross Blue Shield of Illinois Might Deny Enbrel Coverage

 

Reasons for Enbrel Coverage Denial

 

  • Blue Cross Blue Shield of Illinois might deny coverage for Enbrel if the patient does not meet the specified medical necessity criteria outlined in their policy guidelines.
  •  

  • Coverage may be denied if prior authorization was not obtained. Enbrel often requires prior authorization to ensure the medication is appropriate for the patient's condition.
  •  

  • If the prescribing physician failed to provide sufficient documentation of the patient's diagnosis and previous treatment failures, coverage might be denied.
  •  

  • Enbrel coverage could be declined if it's being prescribed for an unapproved or off-label use that isn't supported by adequate clinical evidence recognized by Blue Cross Blue Shield of Illinois.
  •  

  • The patient not meeting age restrictions or other demographic criteria, as stipulated in the plan’s policy, can lead to denial of coverage.
  •  

  • Coverage may be refused if Enbrel is not included in the insured's specific plan's formulary. Non-formulary medications often require special approval or are not covered at all.
  •  

  • Failure to follow step therapy protocols, where a patient must try and fail cheaper or preferred alternatives before coverage for Enbrel is granted, can result in denial.
  •  

  • If the policy excludes specific medical conditions that Enbrel treats, such as certain forms of arthritis, from coverage, claims involving those diagnoses may be denied.

 

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 of Illinois

 

Contact Blue Cross Blue Shield of Illinois

 

  • Reach out to Blue Cross Blue Shield of Illinois (BCBSIL) by calling the customer service number provided on your insurance card. Ask for specific information regarding coverage criteria and procedures for Enbrel.
  •  

  • Visit the BCBSIL official website to review their formulary and see if Enbrel is listed as a covered medication.

 

Consult Your Healthcare Provider

 

  • Discuss with your healthcare provider about your need for Enbrel and ensure that it is medically necessary for your condition. Your doctor may need to provide documentation or a letter of medical necessity to the insurance company.
  •  

  • Have your healthcare provider check if there are any specific forms or additional information required by BCBSIL to facilitate the approval process for Enbrel.

 

Check Your Insurance Plan Details

 

  • Log into your BCBSIL account online to review your benefits and coverage specific to prescription drugs. Look for information on specialty drugs and biologics, as Enbrel may fall under this category.
  •  

  • Understand any possible out-of-pocket costs, such as copays or deductibles related to obtaining Enbrel, and check if there are specific network pharmacies or mail-order options for specialty drugs.

 

Prior Authorization Process

 

  • Determine if Enbrel requires prior authorization by contacting BCBSIL or reviewing your plan’s policy. If required, your healthcare provider will need to submit a prior authorization request.
  •  

  • Ensure all necessary paperwork is accurately completed and submitted. This may include medical records and a treatment history.

 

Follow Up on Authorization

 

  • After submitting the prior authorization, follow up with BCBSIL and your healthcare provider to monitor the status of the request.
  •  

  • If approved, you will receive information on how to proceed with obtaining Enbrel. If denied, review the reasons and explore options for appeal if necessary.

 

Fill Your Prescription

 

  • Once approved, fill your prescription for Enbrel at an in-network pharmacy or through a specialty pharmacy if required by your plan.
  •  

  • Verify the details with the pharmacy regarding copayment amounts and the process for refills, to ensure smooth continuity of your treatment.

 

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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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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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