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Does Florida Blue (Blue Cross Blue Shield of Florida) Cover Enbrel

Explore Florida Blue's Enbrel coverage, understand reasons for denial, learn how to secure coverage, discover costs, and get answers to common questions.

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Does Florida Blue Cover Enbrel?

Florida Blue (Blue Cross Blue Shield of Florida) typically covers Enbrel for approved medical conditions such as rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, ankylosing spondylitis, and juvenile idiopathic arthritis.

Coverage usually requires prior authorization, where the provider must demonstrate medical necessity based on established criteria.

Patients may need to try and fail less expensive treatment options before Enbrel is approved under step therapy protocols.

Prescription benefit plans may have specific formularies, where Enbrel could be classified under a specialty tier with higher copayments or coinsurance responsibilities.

Checking with Florida Blue directly or consulting the member handbook can confirm the exact coverage details, as policies may vary.

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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.

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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 Florida Blue (Blue Cross Blue Shield of Florida)

Research Your Plan

Log in to your Florida Blue account to check your specific health plan details and understand the prescription drug benefits it offers.

Identify any particular formulary or coverage requirements for Enbrel under your specific plan.

Consult Your Healthcare Provider

Schedule a meeting with your healthcare provider to discuss the necessity of Enbrel for your treatment.

Ensure they provide detailed documentation on why Enbrel is needed and any previous treatments that have been tried without success.

Check for Pre-Authorization Requirements

Contact Florida Blue customer service or check their online portal to determine if Enbrel requires pre-authorization.

Gather any necessary forms or documents that your healthcare provider might need to fill out to obtain this pre-authorization.

Submit a Pre-Authorization Request

Work with your healthcare provider to submit a completed pre-authorization request to Florida Blue.

Ensure that all supporting documents, such as medical necessity forms and prior treatment records, are included.

Follow Up on the Pre-Authorization

Contact Florida Blue regularly to check on the status of your pre-authorization request.

If additional information is requested, quickly coordinate with your healthcare provider to supply the necessary details.

Appeal if Necessary

If the pre-authorization is denied, review the denial letter for specific reasons and instructions for appeal.

Gather any additional documentation that may support the use of Enbrel, such as further medical rationale or endorsements from specialists.

Submit an appeal to Florida Blue following their specified process, and keep a detailed record of all communications related to the appeal.

Utilize Florida Blue Support Resources

Explore additional support resources offered by Florida Blue, such as patient advocacy or pharmacy specialists, who might assist in the pre-authorization or appeal process.

Consider contacting patient assistance programs provided by the Enbrel manufacturer for financial assistance or guidance through insurance processes.

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FAQs

Does Florida Blue (Blue Cross Blue Shield of Florida) Cover Enbrel

Explore Florida Blue's Enbrel coverage, understand reasons for denial, learn how to secure coverage, discover costs, and get answers to common questions.

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Is Enbrel Covered by Florida Blue (Blue Cross Blue Shield of Florida)

Does Florida Blue Cover Enbrel?

Florida Blue (Blue Cross Blue Shield of Florida) typically covers Enbrel for approved medical conditions such as rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, ankylosing spondylitis, and juvenile idiopathic arthritis.

Coverage usually requires prior authorization, where the provider must demonstrate medical necessity based on established criteria.

Patients may need to try and fail less expensive treatment options before Enbrel is approved under step therapy protocols.

Prescription benefit plans may have specific formularies, where Enbrel could be classified under a specialty tier with higher copayments or coinsurance responsibilities.

Checking with Florida Blue directly or consulting the member handbook can confirm the exact coverage details, as policies may vary.

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Florida Blue (Blue Cross Blue Shield of Florida)'s Approved Criteria for Enbrel Coverage

Coverage Criteria for Enbrel

Enbrel is covered for the treatment of rheumatoid arthritis in patients who are 18 years or older and have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

For psoriatic arthritis, coverage is approved for individuals 18 years or older with a history of inadequate response to previous DMARD therapy.

In the case of ankylosing spondylitis, Enbrel is authorized for those 18 years or older with active disease and an inadequate response to standard therapies.

For individuals with plaque psoriasis, Enbrel is covered for those 18 years or older with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy and have failed to respond to, or have a contraindication to, other systemic therapy.

For juvenile idiopathic arthritis (JIA), Enbrel is covered for patients 2 years and older with moderate to severe active polyarticular JIA who have had an inadequate response to one or more DMARDs.

Required Documentation

An official diagnosis from the treating healthcare provider must be provided, specifying the condition for which Enbrel is being prescribed.

Submission of previous treatment history and evidence of an inadequate response to prior therapies as stated in the criteria above.

Clinical records supporting the diagnosis and the necessity for Enbrel treatment based on disease severity and prior treatment outcomes.

Renewal Criteria

Continued coverage of Enbrel for the approved conditions requires evidence of positive clinical response upon reevaluation.

Submission of updated clinical notes demonstrating improvement or stabilization of the condition since the initiation of Enbrel therapy is required.

Age and Condition Specific Criteria

Enbrel is specifically approved for use in adults 18 years and older, except in cases of juvenile idiopathic arthritis where patients 2 years and older are eligible for coverage.

Each condition has specific age and response criteria as detailed in the coverage criteria section.

Why Florida Blue (Blue Cross Blue Shield of Florida) Might Deny Enbrel Coverage

Situations When Florida Blue Might Deny Enbrel Coverage

**Experimental or Investigational Use**: If Enbrel is being prescribed for any experimental or investigational use that hasn't been approved by the FDA or does not align with established clinical guidelines and practices.

**Lack of Authorized Prescriber**: If the prescription for Enbrel is not provided by an authorized healthcare professional, such as a licensed rheumatologist or dermatologist.

**Non-Covered Indications**: When Enbrel is prescribed for conditions that are not covered under the plan benefits. This might include off-label uses that have not been accepted as a standard therapy.

**Failure to Meet Prior Authorization Requirements**: If prior authorization protocols are not met, including the submission of necessary documentation or proof that Enbrel is a necessary treatment based on the insured's medical history.

**Exceeding Quantity Limits**: Prescriptions that exceed the recommended or approved dosage may be denied unless there is a particular medical justification.

**Availability of Lower-Cost Alternatives**: If Florida Blue determines that a more cost-effective and equally effective medication is available, they may deny coverage for Enbrel.

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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 Florida Blue (Blue Cross Blue Shield of Florida)

Research Your Plan

Log in to your Florida Blue account to check your specific health plan details and understand the prescription drug benefits it offers.

Identify any particular formulary or coverage requirements for Enbrel under your specific plan.

Consult Your Healthcare Provider

Schedule a meeting with your healthcare provider to discuss the necessity of Enbrel for your treatment.

Ensure they provide detailed documentation on why Enbrel is needed and any previous treatments that have been tried without success.

Check for Pre-Authorization Requirements

Contact Florida Blue customer service or check their online portal to determine if Enbrel requires pre-authorization.

Gather any necessary forms or documents that your healthcare provider might need to fill out to obtain this pre-authorization.

Submit a Pre-Authorization Request

Work with your healthcare provider to submit a completed pre-authorization request to Florida Blue.

Ensure that all supporting documents, such as medical necessity forms and prior treatment records, are included.

Follow Up on the Pre-Authorization

Contact Florida Blue regularly to check on the status of your pre-authorization request.

If additional information is requested, quickly coordinate with your healthcare provider to supply the necessary details.

Appeal if Necessary

If the pre-authorization is denied, review the denial letter for specific reasons and instructions for appeal.

Gather any additional documentation that may support the use of Enbrel, such as further medical rationale or endorsements from specialists.

Submit an appeal to Florida Blue following their specified process, and keep a detailed record of all communications related to the appeal.

Utilize Florida Blue Support Resources

Explore additional support resources offered by Florida Blue, such as patient advocacy or pharmacy specialists, who might assist in the pre-authorization or appeal process.

Consider contacting patient assistance programs provided by the Enbrel manufacturer for financial assistance or guidance through insurance processes.

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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 Florida Blue (Blue Cross Blue Shield of Florida) Cover Enbrel

Explore Florida Blue's Enbrel coverage, understand reasons for denial, learn how to secure coverage, discover costs, and get answers to common questions.

Achieve Your Goals Faster with Curex