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Does Blue Shield of California Cover Enbrel

Discover Enbrel coverage with Blue Shield of California, reasons for denial, steps to gain approval, and costs without insurance in this comprehensive guide.

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Does Blue Shield of California Cover Enbrel?

Blue Shield of California typically covers Enbrel for conditions like rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.

Coverage often requires prior authorization, meaning healthcare providers must justify its necessity based on medical criteria.

Patients may need to try other treatments first (step therapy) before Enbrel is approved.

Dosage and quantity limits may apply, aligned with FDA-approved labeling and clinical guidelines.

Copays or coinsurance can vary based on the specific plan and whether Enbrel is classified as a preferred or non-preferred drug.

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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 Shield of California

Initial Steps to Check Coverage

Visit the Blue Shield of California website and log in or create an account to access your healthcare plan details.

Review your specific health plan summary to understand if prescription drug coverage for Enbrel is included.

Consultation with Your Healthcare Provider

Discuss your Enbrel treatment plan with your healthcare provider to confirm the necessity and dosage.

Request any documentation or justification your provider can supply for the prescription to support coverage requests.

Check for Formulary Inclusion

Access the Blue Shield of California drug formulary list online to check if Enbrel is included and understand any specific coverage criteria.

Note any prerequisite requirements, such as prior authorizations or step therapy, that may be associated with Enbrel coverage.

Verify Prior Authorization Requirements

Discuss with your healthcare provider if prior authorization is needed, which is common for biologic medications like Enbrel.

If required, ensure that your healthcare provider submits the necessary prior authorization request to Blue Shield of California.

Contact Blue Shield Customer Support

Call Blue Shield of California's customer service number to confirm coverage details, including copays or tier levels for Enbrel.

Inquire about any specific documentation or processes needed to facilitate the authorization and coverage of Enbrel.

Submit Claims and Follow Up

Ensure your pharmacy submits any required claims directly to Blue Shield for processing when you fill your Enbrel prescription.

Keep detailed records of all communications, receipts, and documentation submitted to track the status of your coverage or claim.

Regularly follow up with Blue Shield and your pharmacy to ensure continued coverage for refills and to address any potential issues quickly.

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Apply treatments in minutes from the comfort of your own home with under-the-tongue applications instead of shots or pills

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Sublingual immunotherapy delivers a higher dose of allergens over the course of treatment.

Potential for results in as few as 6 months

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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Studies that have been reviewed by certified physicians show that sublingual immunotherapy is a safe treatment option

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FAQs

Does Blue Shield of California Cover Enbrel

Discover Enbrel coverage with Blue Shield of California, reasons for denial, steps to gain approval, and costs without insurance in this comprehensive guide.

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Is Enbrel Covered by Blue Shield of California

Does Blue Shield of California Cover Enbrel?

Blue Shield of California typically covers Enbrel for conditions like rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.

Coverage often requires prior authorization, meaning healthcare providers must justify its necessity based on medical criteria.

Patients may need to try other treatments first (step therapy) before Enbrel is approved.

Dosage and quantity limits may apply, aligned with FDA-approved labeling and clinical guidelines.

Copays or coinsurance can vary based on the specific plan and whether Enbrel is classified as a preferred or non-preferred drug.

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Blue Shield of California's Approved Criteria for Enbrel Coverage

Criteria for Enbrel Coverage

Enbrel is covered for the treatment of rheumatoid arthritis if the patient has moderate to severe active disease and has had an inadequate response or intolerance to one or more disease-modifying anti-rheumatic drugs (DMARDs).

Coverage is approved for psoriatic arthritis in patients with active disease, with or without methotrexate, for improving physical function and reducing structural damage.

For ankylosing spondylitis, coverage is provided when the patient has active disease and has experienced an inadequate response to conventional therapy.

Enbrel is covered for the treatment of plaque psoriasis in adult patients with chronic moderate to severe disease who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate.

Approval for juvenile idiopathic arthritis is granted if the patient has moderate to severe active polyarticular disease and has had inadequate responses to one or more DMARDs.

Why Blue Shield of California Might Deny Enbrel Coverage

Reasons for Denial of Enbrel Coverage by Blue Shield of California

Enbrel is prescribed for conditions that are not FDA-approved or not recognized by Blue Shield of California as medically necessary.

The patient does not meet the specific medical criteria or guidelines set by Blue Shield of California for Enbrel usage, such as clinical documentation of appropriate diagnosis.

There is a lack of sufficient evidence or documentation to support the necessity and efficacy of Enbrel for the requested condition, as per the plan’s medical policy guidelines.

A more cost-effective or preferred alternative treatment is deemed available and appropriate, and the use of Enbrel is considered not economically justified under the patient's insurance plan.

Prescriptions are not filled by an in-network provider or without prior authorization when required by the insurance plan.

The usage of Enbrel is outside the approved dosage or duration limits set by the insurance 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.

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 Enbrel Coverage with Blue Shield of California

Initial Steps to Check Coverage

Visit the Blue Shield of California website and log in or create an account to access your healthcare plan details.

Review your specific health plan summary to understand if prescription drug coverage for Enbrel is included.

Consultation with Your Healthcare Provider

Discuss your Enbrel treatment plan with your healthcare provider to confirm the necessity and dosage.

Request any documentation or justification your provider can supply for the prescription to support coverage requests.

Check for Formulary Inclusion

Access the Blue Shield of California drug formulary list online to check if Enbrel is included and understand any specific coverage criteria.

Note any prerequisite requirements, such as prior authorizations or step therapy, that may be associated with Enbrel coverage.

Verify Prior Authorization Requirements

Discuss with your healthcare provider if prior authorization is needed, which is common for biologic medications like Enbrel.

If required, ensure that your healthcare provider submits the necessary prior authorization request to Blue Shield of California.

Contact Blue Shield Customer Support

Call Blue Shield of California's customer service number to confirm coverage details, including copays or tier levels for Enbrel.

Inquire about any specific documentation or processes needed to facilitate the authorization and coverage of Enbrel.

Submit Claims and Follow Up

Ensure your pharmacy submits any required claims directly to Blue Shield for processing when you fill your Enbrel prescription.

Keep detailed records of all communications, receipts, and documentation submitted to track the status of your coverage or claim.

Regularly follow up with Blue Shield and your pharmacy to ensure continued coverage for refills and to address any potential issues quickly.

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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. 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 Shield of California Cover Enbrel

Discover Enbrel coverage with Blue Shield of California, reasons for denial, steps to gain approval, and costs without insurance in this comprehensive guide.

Achieve Your Goals Faster with Curex