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Does Blue Cross Blue Shield of North Carolina Cover Orencia

Discover coverage details for Orencia with BCBS NC. Learn why coverage might be denied, how to secure it, costs without insurance, and answers to common FAQs.

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Coverage for Orencia

Blue Cross Blue Shield of North Carolina (BCBSNC) typically covers Orencia for conditions like rheumatoid arthritis, juvenile idiopathic arthritis, and psoriatic arthritis.

Coverage is subject to the terms and limitations of the member's specific insurance plan.

Orencia may require prior authorization, meaning your healthcare provider must obtain approval from BCBSNC before the medication is covered.

Criteria for Coverage

Patients may need to demonstrate an inadequate response to one or more Disease-Modifying Antirheumatic Drugs (DMARDs) before Orencia is covered.

Documentation of the diagnosis and previous treatment history is often required.

BCBSNC may have quantity limits and formulary restrictions that dictate how much medication can be received over a certain period.

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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 Blue Cross Blue Shield of North Carolina

Check Your Plan Details

Contact Blue Cross Blue Shield of North Carolina (BCBSNC) customer service using the number on your insurance card to inquire if Orencia is covered under your specific plan.

Review your insurance documents, such as the policy booklet or online account, to see any mention of Orencia or specialty drugs.

Visit Your Doctor

Schedule an appointment with your healthcare provider to discuss your condition and the need for Orencia. Ensure you have documentation from your provider stating the medical necessity of the treatment.

Ask your doctor to provide any necessary information or documents that BCBSNC might require when evaluating your coverage request for Orencia.

Pre-authorization Requirement

Ask BCBSNC if Orencia requires pre-authorization. You'll need to submit a pre-authorization request through your doctor to start the approval process if required.

Ensure all forms are filled out accurately and include supporting medical documents to expedite the review process.

Submit a Claim

Work with your doctor’s office to submit a claim to BCBSNC for Orencia. This might involve completing specific claim forms provided by your doctor’s office or from BCBSNC.

Include copies of pre-authorization and any other communications that may support your claim.

Follow Up

After submission, regularly contact BCBSNC to follow up on the status of your claim. It's essential to keep track of deadlines to ensure timely approval.

Document communications, including dates and times of calls and the names of representatives you talk to for reference.

Appeal if Necessary

If BCBSNC denies your claim, review the denial letter to understand the specific reason for denial. This will guide you on how to address the issues for an appeal.

Work with your healthcare provider to gather additional documentation or any new supportive medical evidence that can aid your appeal.

Use Patient Assistance Programs

While waiting for resolution, investigate Orencia's manufacturer patient assistance programs that might provide temporary support or discounts.

Consult with your doctor or pharmacy to assist in accessing these programs if BCBSNC is slow in processing your request.

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FAQs

Does Blue Cross Blue Shield of North Carolina Cover Orencia

Discover coverage details for Orencia with BCBS NC. Learn why coverage might be denied, how to secure it, costs without insurance, and answers to common FAQs.

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Is Orencia Covered by Blue Cross Blue Shield of North Carolina

Coverage for Orencia

Blue Cross Blue Shield of North Carolina (BCBSNC) typically covers Orencia for conditions like rheumatoid arthritis, juvenile idiopathic arthritis, and psoriatic arthritis.

Coverage is subject to the terms and limitations of the member's specific insurance plan.

Orencia may require prior authorization, meaning your healthcare provider must obtain approval from BCBSNC before the medication is covered.

Criteria for Coverage

Patients may need to demonstrate an inadequate response to one or more Disease-Modifying Antirheumatic Drugs (DMARDs) before Orencia is covered.

Documentation of the diagnosis and previous treatment history is often required.

BCBSNC may have quantity limits and formulary restrictions that dictate how much medication can be received over a certain period.

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Blue Cross Blue Shield of North Carolina's Approved Criteria for Orencia Coverage

Orencia Coverage Criteria Overview

Orencia (abatacept) is covered by Blue Cross Blue Shield of North Carolina for specific medical conditions where its efficacy and safety have been established.

Rheumatoid Arthritis (RA)

Orencia is authorized for adult patients diagnosed with moderate to severe active rheumatoid arthritis.
Prior unsuccessful response or intolerance to one or more disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, is required.
Can be used as monotherapy or in combination with DMARDs other than tumor necrosis factor (TNF) antagonists.

Juvenile Idiopathic Arthritis (JIA)

Eligible for covering polyarticular juvenile idiopathic arthritis in pediatric patients aged two years and older.
Typically prescribed following an inadequate response to one or more DMARDs or biologics.

Plaque Psoriasis (PsO)

Orencia coverage is provided for patients with moderate to severe plaque psoriasis.
Treatment is generally recommended for patients who are also candidates for systemic therapy or phototherapy.

Psoriatic Arthritis (PsA)

Approved for adult patients with active psoriatic arthritis.
Coverage is based on previous failure or inability to tolerate recommended DMARDs or TNF inhibitors.
Orencia can be combined with a non-biologic DMARD for enhanced treatment.

Administration Requirements

Orencia must be prescribed and administered by a healthcare professional with experience managing patients with the indicated conditions.
Appropriate dosing as per current medical guidelines is a prerequisite for coverage.

Step Therapy Protocols

When applicable, step therapy protocols must be followed, requiring the trial and intolerance or failure of one or more preferred medications before Orencia is covered.

Clinical Documentation

Submission of detailed clinical documentation may be necessary to establish the eligibility criteria for Orencia coverage.
This can include prior medication history, response records, and current disease activity assessment.

Why Blue Cross Blue Shield of North Carolina Might Deny Orencia Coverage

Reasons Blue Cross Blue Shield of North Carolina Might Deny Orencia Coverage

Orencia is prescribed for a condition that is not FDA-approved or is considered experimental for treatment purposes.

The prescribed use of Orencia does not meet the established clinical criteria set forth by Blue Cross Blue Shield of North Carolina.

The prescription does not align with the step therapy requirements, meaning more cost-effective or clinically recognized alternatives have not been tried first.

The treatment lacks necessary documentation, such as inadequate evidence of disease severity or failure of previous therapies as required by Blue Cross Blue Shield of North Carolina's policy.

Prescriptions that exceed dosage limits recommended by FDA guidelines or lack necessary pre-authorization or physician justification.

When the prescribed Orencia is for off-label use without sufficient supporting evidence from clinical studies or peer-reviewed literature to justify treatment.

If the patient's current insurance plan does not provide a prescription drug coverage option in which Orencia is included or 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 Blue Cross Blue Shield of North Carolina

Check Your Plan Details

Contact Blue Cross Blue Shield of North Carolina (BCBSNC) customer service using the number on your insurance card to inquire if Orencia is covered under your specific plan.

Review your insurance documents, such as the policy booklet or online account, to see any mention of Orencia or specialty drugs.

Visit Your Doctor

Schedule an appointment with your healthcare provider to discuss your condition and the need for Orencia. Ensure you have documentation from your provider stating the medical necessity of the treatment.

Ask your doctor to provide any necessary information or documents that BCBSNC might require when evaluating your coverage request for Orencia.

Pre-authorization Requirement

Ask BCBSNC if Orencia requires pre-authorization. You'll need to submit a pre-authorization request through your doctor to start the approval process if required.

Ensure all forms are filled out accurately and include supporting medical documents to expedite the review process.

Submit a Claim

Work with your doctor’s office to submit a claim to BCBSNC for Orencia. This might involve completing specific claim forms provided by your doctor’s office or from BCBSNC.

Include copies of pre-authorization and any other communications that may support your claim.

Follow Up

After submission, regularly contact BCBSNC to follow up on the status of your claim. It's essential to keep track of deadlines to ensure timely approval.

Document communications, including dates and times of calls and the names of representatives you talk to for reference.

Appeal if Necessary

If BCBSNC denies your claim, review the denial letter to understand the specific reason for denial. This will guide you on how to address the issues for an appeal.

Work with your healthcare provider to gather additional documentation or any new supportive medical evidence that can aid your appeal.

Use Patient Assistance Programs

While waiting for resolution, investigate Orencia's manufacturer patient assistance programs that might provide temporary support or discounts.

Consult with your doctor or pharmacy to assist in accessing these programs if BCBSNC is slow in processing your request.

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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 Blue Cross Blue Shield of North Carolina Cover Orencia

Discover coverage details for Orencia with BCBS NC. Learn why coverage might be denied, how to secure it, costs without insurance, and answers to common FAQs.

Achieve Your Goals Faster with Curex