Does Fallon Community Health Plan (FCHP) Cover Enbrel

Explore Enbrel coverage under Fallon Community Health Plan. Learn about coverage denial, obtaining approval, costs without insurance, and FAQs.
Curex allergy drops unboxing
“Curex is changing the landscape of allergies in 2024”
man opening Curex packaging
man opening Curex packaging

 

Fallon Community Health Plan (FCHP) Coverage for Enbrel

 

  • FCHP may cover Enbrel for chronic conditions like rheumatoid arthritis and psoriasis.
  •  

  • Coverage often requires prior authorization to confirm medical necessity and compliance with treatment guidelines.
  •  

  • Patients must have a confirmed diagnosis by a healthcare provider to qualify for coverage.
  •  

  • Typically, proof of unsuccessful previous standard therapies is necessary before approval.
  •  

  • For detailed coverage information, members should consult their specific FCHP plan documents or contact customer service.

 

Want to try immunotherapy?

Start with Curex

Covered

Uncovered

Treat your allergies with Curex - $49  $9.99

Review your allergy test results with a Curex allergist.

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 Fallon Community Health Plan (FCHP)

 

Contact Fallon Community Health Plan (FCHP) Member Services

 

  • Reach out to FCHP Member Services through their customer service number found on your insurance card. Inquire about your benefits and coverage for Enbrel (etanercept), a prescription medication.
  •  

  • Request information regarding prior authorization requirements for Enbrel, as these are common for specialty medications like Enbrel.

 

Consult with Your Healthcare Provider

 

  • Discuss your medical need for Enbrel with your healthcare provider. Ensure your provider documents the necessity of Enbrel clearly in your medical records.
  •  

  • Ask your healthcare provider to write a prescription for Enbrel, specifying your diagnosis and any prior treatments you have tried.
  •  

  • Request your healthcare provider to complete any necessary prior authorization forms that Fallon Community Health Plan may require for Enbrel coverage.

 

Gather Necessary Documentation

 

  • Collect all pertinent documents, including doctor's notes, prescription details, your medical history, and the completed prior authorization forms.
  •  

  • Ensure any additional information, such as how Enbrel is expected to improve your condition, is included, as it may strengthen your case for approval.

 

Submit Prior Authorization Request

 

  • Submit the completed prior authorization request along with the necessary documentation to Fallon Community Health Plan. This can often be done through your healthcare provider or directly via mail or fax as instructed by FCHP.
  •  

  • Confirm receipt of your documentation with FCHP to avoid any misunderstandings or lost paperwork.

 

Follow Up on the Authorization Status

 

  • FCHP will review your request and notify you of their decision. This process can take several days to weeks. Regularly follow up with FCHP during this period to stay informed about the status of your request.
  •  

  • If approved, proceed with filling your Enbrel prescription at an in-network pharmacy covered by FCHP.
  •  

  • If denied, ask for the specific reasons for the denial and the appeals process. Utilize your right to appeal, providing any additional documentation that could support your case.

 

Ensure Proper Coverage Implementation

 

  • Once approved, check that your prescription for Enbrel is properly covered and the expected costs (such as co-pays) align with your benefits under FCHP.
  •  

  • Maintain continuous communication with your healthcare provider and pharmacist to ensure you are receiving your medication as prescribed.

 

Curex allergy drops unboxing

We love helping people!

Allie, Nevada

five stars

"I have two cats I can finally cuddle!"

Cat and dog allergies

Zachary, Texas

five stars

“I can breathe through my nose for the first time in like 20 years!"

dust allergy
mold allergy

Dust and mold allergies

Erika, New York

five stars

“I've noticed less sneezing and shortness of breath.”

tree allergy
grass allergy

Tree and grass allergies

Richard, Texas

five stars


I love the convenience!

tree allergy

Tree and cat allergies

We Treat Food, Indoor & Outdoor Allergies

tree allergy
Tree Pollens
maple leaf icon
Weed Pollens
Cat Allergies
Dog Allergies
insect icon
Dust Mites
mold allergy
Molds
Food Allergies
 curex user showing allergy treatment kita patient showing allergy treatment boxa male patient showing allergy drops vial
50,000+ users have overcome their allergies
Am I eligible?

Benefits of Curex

At-home treatment

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

5-30x higher cumulative dose vs allergy shots

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

Excellent safety profile

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

Treatment prescribed
by clinician

1
right line icon
Curex packaging

Clinicaly made allergen extracts are customized for your allergies

2
right line icon
insect icon
grass icon
man opening Curex packaging

Your immune system gets desensitized to allergens, giving you long-term relief.

3

FAQs

Does Fallon Community Health Plan (FCHP) Cover Enbrel

Explore Enbrel coverage under Fallon Community Health Plan. Learn about coverage denial, obtaining approval, costs without insurance, and FAQs.
Curex allergy drops unboxing

Is Enbrel Covered by Fallon Community Health Plan (FCHP)

 

Fallon Community Health Plan (FCHP) Coverage for Enbrel

 

  • FCHP may cover Enbrel for chronic conditions like rheumatoid arthritis and psoriasis.
  •  

  • Coverage often requires prior authorization to confirm medical necessity and compliance with treatment guidelines.
  •  

  • Patients must have a confirmed diagnosis by a healthcare provider to qualify for coverage.
  •  

  • Typically, proof of unsuccessful previous standard therapies is necessary before approval.
  •  

  • For detailed coverage information, members should consult their specific FCHP plan documents or contact customer service.

 

A weight management program tailored to you

Start with Curex

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

 

Criteria for Fallon Community Health Plan (FCHP) Enbrel Coverage

 

  • **Diagnosis with an Indication**: The patient must have a confirmed diagnosis of one of the following conditions:
    • Rheumatoid Arthritis (RA)
    • Psoriatic Arthritis (PsA)
    • Ankylosing Spondylitis (AS)
    • Plaque Psoriasis (PsO) for patients 18 years or older
    • Juvenile Idiopathic Arthritis (JIA) for patients aged 2 years or older
  •  

  • **Previous Treatment**: The patient should have tried and failed, or have contraindications to at least one conventional therapy relevant to their condition, such as Methotrexate for RA.
  •  

  • **Comprehensive Evaluation**: Submission of a comprehensive clinical evaluation from a qualified healthcare provider detailing the severity of the disease, previous treatment history, and current symptoms.
  •  

  • **Prescribed by a Specialist**: Enbrel must be prescribed by a rheumatologist, dermatologist, or another specialist experienced in the treatment of conditions Enbrel is approved for.
  •  

  • **Dosing Requirements**: The dosage prescribed should follow the FDA-approved dosing guidelines for the specific condition being treated.
  •  

  • **Continued Coverage**: For continued coverage beyond an initial approval period:
    • The patient’s health records should demonstrate an adequate response to Enbrel, as evidenced by a decrease in disease activity or improvement in symptoms.
    • Regular assessment by the prescribing specialist is required, which must include a periodic review of the patient’s progress and the appropriateness of continuing Enbrel therapy.

 

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

 

Reasons for Denial of Enbrel Coverage by FCHP

 

  • **Non-Approved Uses**: FCHP does not cover Enbrel for off-label indications that are not recognized in their coverage criteria. Requests for Enbrel must align with FDA-approved indications or evidence-based guidelines acknowledged by the plan.
  •  

  • **Lack of Medical Necessity**: Enbrel is not covered if it is determined that the treatment is not medically necessary. Medical necessity is evaluated based on member-specific clinical conditions and does not match FCHP's guidelines.
  •  

  • **Prior Authorization Not Obtained**: Coverage can be denied if prior authorization is not sought or is not granted. FCHP requires any treatments like Enbrel to be authorized before coverage can be considered.
  •  

  • **Failure of Step Therapy Protocols**: Enbrel is not covered if step therapy requirements are not fulfilled. FCHP might require a trial of less costly medications before approving Enbrel unless specific conditions are met.
  •  

  • **Missing or Incomplete Documentation**: Denial occurs if application lacks complete documentation, such as requisite medical records or statement of necessary condition as required by FCHP policy.
  •  

  • **Non-Compliance with Plan's Terms**: If the usage of Enbrel does not comply with the terms outlined in the member's plan, coverage might be denied. This includes cases where Enbrel is used in a way not supported by the plan's conditions.

 

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 Fallon Community Health Plan (FCHP)

 

Contact Fallon Community Health Plan (FCHP) Member Services

 

  • Reach out to FCHP Member Services through their customer service number found on your insurance card. Inquire about your benefits and coverage for Enbrel (etanercept), a prescription medication.
  •  

  • Request information regarding prior authorization requirements for Enbrel, as these are common for specialty medications like Enbrel.

 

Consult with Your Healthcare Provider

 

  • Discuss your medical need for Enbrel with your healthcare provider. Ensure your provider documents the necessity of Enbrel clearly in your medical records.
  •  

  • Ask your healthcare provider to write a prescription for Enbrel, specifying your diagnosis and any prior treatments you have tried.
  •  

  • Request your healthcare provider to complete any necessary prior authorization forms that Fallon Community Health Plan may require for Enbrel coverage.

 

Gather Necessary Documentation

 

  • Collect all pertinent documents, including doctor's notes, prescription details, your medical history, and the completed prior authorization forms.
  •  

  • Ensure any additional information, such as how Enbrel is expected to improve your condition, is included, as it may strengthen your case for approval.

 

Submit Prior Authorization Request

 

  • Submit the completed prior authorization request along with the necessary documentation to Fallon Community Health Plan. This can often be done through your healthcare provider or directly via mail or fax as instructed by FCHP.
  •  

  • Confirm receipt of your documentation with FCHP to avoid any misunderstandings or lost paperwork.

 

Follow Up on the Authorization Status

 

  • FCHP will review your request and notify you of their decision. This process can take several days to weeks. Regularly follow up with FCHP during this period to stay informed about the status of your request.
  •  

  • If approved, proceed with filling your Enbrel prescription at an in-network pharmacy covered by FCHP.
  •  

  • If denied, ask for the specific reasons for the denial and the appeals process. Utilize your right to appeal, providing any additional documentation that could support your case.

 

Ensure Proper Coverage Implementation

 

  • Once approved, check that your prescription for Enbrel is properly covered and the expected costs (such as co-pays) align with your benefits under FCHP.
  •  

  • Maintain continuous communication with your healthcare provider and pharmacist to ensure you are receiving your medication as prescribed.

 

Premium Medication you can trust

Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

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.

 

Have questions left?

Get a personalized online consultation with a doctor at Curex

Curex is one of America’s largest telehealth providers

Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
journey now

Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

A weight management program tailored to you

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.

Made in Webflow