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Does Fallon Community Health Plan (FCHP) Cover Dupixent

Explore Dupixent coverage with FCHP, reasons for denial, how to appeal, costs without insurance, and FAQs about this essential treatment.

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Does FCHP Cover Dupixent?

Fallon Community Health Plan covers Dupixent for specific conditions such as moderate-to-severe atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyps.

Coverage is subject to criteria, including prior authorization and confirmation that other treatments have failed or are not suitable.

Basic Rules for Dupixent Coverage

Members need documented evidence of ineffective previous therapies or contraindications to justify Dupixent use.

Physicians must submit prior authorization requests highlighting medical necessity and providing complete clinical documentation.

Continued use requires periodic evaluation to ensure therapeutic benefit and adherence to prescribed protocol.

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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 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 Dupixent Coverage with Fallon Community Health Plan (FCHP)

Consult Your Healthcare Provider

Discuss with your healthcare provider about the necessity of Dupixent for your condition.

Request that they provide the necessary documentation to justify the medical need for Dupixent to Fallon Community Health Plan.

Verify Coverage and Eligibility

Contact Fallon Community Health Plan directly to confirm whether Dupixent is covered under your specific plan.

Check if there are any prerequisites, such as prior authorization or step therapy, required for coverage.

Gather Required Documents

Compile all necessary documentation, including medical records, doctor's notes, and any prior treatments attempted.

Ensure you have your Fallon Community Health Plan member ID and personal identification details ready.

Submit a Prior Authorization Request

Work with your healthcare provider to complete a prior authorization form, if necessary, for Dupixent coverage.

Include all the gathered documentation to support the request.

Submit the completed form and documents to Fallon Community Health Plan according to their instructions.

Appeal If Necessary

If your initial request is denied, request a detailed explanation from Fallon Community Health Plan.

Submit an appeal with additional justification and supporting evidence if applicable.

Consider seeking assistance from your healthcare provider or a patient advocacy group to strengthen your appeal.

Check for Financial Assistance Programs

Investigate if Dupixent offers any patient assistance programs or copay cards to help reduce out-of-pocket costs.

Consult your healthcare provider or pharmacist for potential manufacturer discounts or assistance options.

Follow Up Regularly

Stay in regular contact with Fallon Community Health Plan to check the status of your request or appeal.

Keep records of all communications and received documents related to your Dupixent coverage process.

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FAQs

Does Fallon Community Health Plan (FCHP) Cover Dupixent

Explore Dupixent coverage with FCHP, reasons for denial, how to appeal, costs without insurance, and FAQs about this essential treatment.

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Is Dupixent Covered by Fallon Community Health Plan (FCHP)

Does FCHP Cover Dupixent?

Fallon Community Health Plan covers Dupixent for specific conditions such as moderate-to-severe atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyps.

Coverage is subject to criteria, including prior authorization and confirmation that other treatments have failed or are not suitable.

Basic Rules for Dupixent Coverage

Members need documented evidence of ineffective previous therapies or contraindications to justify Dupixent use.

Physicians must submit prior authorization requests highlighting medical necessity and providing complete clinical documentation.

Continued use requires periodic evaluation to ensure therapeutic benefit and adherence to prescribed protocol.

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Fallon Community Health Plan (FCHP)'s Approved Criteria for Dupixent Coverage

Fallon Community Health Plan (FCHP) Criteria for Dupixent Coverage

**Diagnosis of Moderate-to-Severe Atopic Dermatitis:**
- Member is 6 years of age or older.
- Failure of topical medication therapies or if these therapies are not advisable.
- Post-diagnosis, member must have a history of inadequate response, intolerance, or contraindication to at least one systemic therapy including but not limited to cyclosporine, methotrexate, or phototherapy.

**Chronic Rhinosinusitis with Nasal Polyps (CRSwNP):**
- Member is 18 years of age or older.
- Failure of systemic corticosteroid therapy unless contraindicated or not tolerated.
- Documented nasal polyposis needing pharmacologic intervention, confirmed by prior sinonasal surgery or imaging.

**Asthma Treatment:**
- Member is 12 years of age or older.
- Diagnosis of moderate-to-severe asthma with eosinophilic phenotype or oral corticosteroid-dependent asthma.
- Inadequate control despite medium to high dose inhaled corticosteroids plus one or more additional asthma controller(s).

**Eosinophilic Esophagitis Criteria:**
- Member is 12 years of age or older.
- Documented eosinophilic esophagitis diagnosis by biopsy.
- Inadequate response to dietary and/or pharmacologic interventions, including proton pump inhibitors and topical corticosteroids.

**Coverage Duration and Authorization:**
- Initial approval is typically for a period of 6 months.
- Continuation beyond initial period demands documented evidence of clinical improvement from baseline measures.

Why Fallon Community Health Plan (FCHP) Might Deny Dupixent Coverage

Non-Compliance with Medical Criteria

Dupixent is not covered if the medical condition does not meet the specific criteria established by Fallon Community Health Plan. This typically includes being off-label or not being within the guidelines for approved usage.

Insufficient documentation or failure to provide necessary medical records that clearly establish the medical necessity of Dupixent according to FCHP’s protocols.

Lack of Prior Authorization

Failure to obtain prior authorization before commencing treatment with Dupixent. FCHP may require this step to evaluate the necessity and proposed effectiveness of the treatment method.

Authorization requests that fail to provide a thorough rationale for Dupixent's use or argue effectively against alternative treatments.

Failure to Try Alternative Treatments

Dupixent may be denied if the patient has not previously tried and failed more conventional or less expensive treatments unless contraindicated or deemed inappropriate by the governing medical guidelines.

Inadequate evidence of unsuccessful trial or contraindications with alternative therapies recommended for specific conditions prior to the request for Dupixent.

Plan Exclusions and Limitations

Dupixent falls under FCHP's list of excluded or limited prescription drugs. Some plans may specifically exclude biologics or have annual coverage caps that could affect authorization.

Requests that exceed coverage limits within a specific time frame or requests for doses higher than those covered by the health plan policy.

Non-Formulary Status

Prescriptions that are outside of the FCHP formulary, which may require the healthcare provider to select an alternative medication or to provide additional justification for why Dupixent is necessary over formulary alternatives.

Failure to demonstrate why formulary alternatives are unsuitable or ineffective for the patient’s specific condition.

Non-Membership Related Issues

In cases where the individual requesting coverage is not an active member of FCHP at the time of the service request, Dupixent coverage may be denied.

Situations where premiums are delinquent, leading to temporary suspension of benefits or coverage, including prescription medications like Dupixent.

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How Much Does Dupixent Cost without Insurance?

Approximate Cost of Dupixent Without Insurance

The cost of Dupixent without insurance can be quite high, usually ranging between $3,200 to $3,500 per month. This cost is for the standard dose, which consists of two pre-filled syringes or injection pens, each containing 300 mg of medication.

Prices can vary depending on the pharmacy, location, and any potential deals or discounts offered by specific pharmacies or third-party services.

Patients are encouraged to explore manufacturer copay cards, patient assistance programs, or discount cards which might be available to help reduce out-of-pocket expenses.

For those requiring treatment for conditions like eczema, asthma, or other approved uses, Dupixent is often administered bi-weekly after an initial loading dose, which should be taken into consideration when calculating monthly or annual expenses.

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 Dupixent Coverage with Fallon Community Health Plan (FCHP)

Consult Your Healthcare Provider

Discuss with your healthcare provider about the necessity of Dupixent for your condition.

Request that they provide the necessary documentation to justify the medical need for Dupixent to Fallon Community Health Plan.

Verify Coverage and Eligibility

Contact Fallon Community Health Plan directly to confirm whether Dupixent is covered under your specific plan.

Check if there are any prerequisites, such as prior authorization or step therapy, required for coverage.

Gather Required Documents

Compile all necessary documentation, including medical records, doctor's notes, and any prior treatments attempted.

Ensure you have your Fallon Community Health Plan member ID and personal identification details ready.

Submit a Prior Authorization Request

Work with your healthcare provider to complete a prior authorization form, if necessary, for Dupixent coverage.

Include all the gathered documentation to support the request.

Submit the completed form and documents to Fallon Community Health Plan according to their instructions.

Appeal If Necessary

If your initial request is denied, request a detailed explanation from Fallon Community Health Plan.

Submit an appeal with additional justification and supporting evidence if applicable.

Consider seeking assistance from your healthcare provider or a patient advocacy group to strengthen your appeal.

Check for Financial Assistance Programs

Investigate if Dupixent offers any patient assistance programs or copay cards to help reduce out-of-pocket costs.

Consult your healthcare provider or pharmacist for potential manufacturer discounts or assistance options.

Follow Up Regularly

Stay in regular contact with Fallon Community Health Plan to check the status of your request or appeal.

Keep records of all communications and received documents related to your Dupixent coverage process.

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Dupixent FAQ

1. What are the common side effects of Dupixent?

Common Side Effects of Dupixent

Injection site reactions: redness, swelling, and pain at the injection site are frequently reported. These reactions usually subside shortly after injection.

Conjunctivitis: Some patients experience symptoms like red, itchy, or watery eyes.

Blepharitis: Inflammation of the eyelids, leading to symptoms such as redness, swelling, and itching, may occur.

Oral herpes: A mild increase in probabilities of cold sores has been noted in some cases.

Sore throat: Some individuals may develop pharyngitis, which manifests as throat discomfort or pain.

2. How does Dupixent work for eczema?

How Dupixent Works for Eczema

Dupixent is a monoclonal antibody that targets interleukin-4 receptor alpha (IL-4Rα).

By blocking IL-4Rα, it inhibits the signaling pathways of IL-4 and IL-13, key cytokines involved in the inflammatory response in eczema.

This leads to a reduction in the overactive immune response, which is characterized by inflammation and itchiness in atopic dermatitis.

As a result, Dupixent helps alleviate symptoms like redness, itch, and skin thickening by modulating the immune response.

3. Is Dupixent used for asthma treatment?

Dupixent for Asthma

Dupixent (dupilumab) is approved for use in the treatment of moderate-to-severe asthma in adults and adolescents (12 years and older).

It is particularly beneficial for patients with eosinophilic asthma or those dependent on oral corticosteroids.

Dupixent acts by targeting and inhibiting the signaling of interleukins IL-4 and IL-13, which play central roles in the inflammatory response involved in asthma.

The medication is administered via subcutaneous injection, typically every two weeks after an initial loading dose.

Clinical trials have shown Dupixent to reduce asthma exacerbations and improve lung function, thereby potentially reducing the need for oral corticosteroids.

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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 Fallon Community Health Plan (FCHP) Cover Dupixent

Explore Dupixent coverage with FCHP, reasons for denial, how to appeal, costs without insurance, and FAQs about this essential treatment.

Achieve Your Goals Faster with Curex