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Does Harvard Pilgrim Health Care Cover Enbrel

Discover if Enbrel is covered by Harvard Pilgrim Health Care, understand potential denial reasons, costs without insurance, and how to secure coverage.

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Coverage of Enbrel

Harvard Pilgrim Health Care generally covers Enbrel for conditions like rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, and juvenile idiopathic arthritis.

Coverage is subject to prior authorization, ensuring that Enbrel is medically necessary for the patient's condition.

Criteria for Coverage

The patient must have failed to respond adequately to one or more DMARDs (Disease-Modifying Antirheumatic Drugs) before Enbrel is considered for coverage.

A detailed medical history and treatment plan must be provided by the healthcare provider to support the need for Enbrel.

Basic Rules

Coverage may vary based on the specific health plan and the tier classification of Enbrel in the formulary.

Patients may have to manage copayments or coinsurance, and the amount depends on their particular plan.

Regular updates and reviews ensure that the coverage criteria are aligned with current medical standards and guidelines.

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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.

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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.

Jill Hamburg, PA - C

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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 Enbrel Coverage with Harvard Pilgrim Health Care

Contact Harvard Pilgrim Health Care Customer Service

Begin by calling Harvard Pilgrim's customer service number located on your member ID card. Inquire about coverage for Enbrel and any potential prerequisites or paperwork needed.

Ask for detailed information on your specific health plan, including any deductibles, copayments, or coinsurance that may apply to Enbrel.

Consult Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss the medical necessity of Enbrel. Ensure that the provider can provide any necessary documentation or letters of medical necessity.

Request your provider to check if a prior authorization is needed and if they can initiate the process on your behalf.

Locate the Prior Authorization Form

Visit the Harvard Pilgrim Health Care website and download the prior authorization form if your doctor hasn't already provided one.

Ensure all necessary personal and medical details are completed accurately on the form.

Submit the Prior Authorization Form

Have your healthcare provider submit the completed prior authorization form along with any support documentation to Harvard Pilgrim.

Ensure you or your healthcare provider follow up to confirm receipt and review any additional information needed for processing.

Review the Coverage Decision

Once the authorization is reviewed, Harvard Pilgrim will inform you of the decision. This may occur via mail or through an online patient portal.

If the request is approved, carefully review the details to understand any conditions or limitations to your coverage.

Explore Alternatives if Denied

If the initial decision is a denial, contact Harvard Pilgrim for specific reasons and inquire about the appeals process.

Work with your healthcare provider to gather additional supporting information to strengthen an appeal.

Stay Informed

Regularly check Harvard Pilgrim's formulary list and updates on Enbrel coverage since healthcare policies can change.

Consider joining patient support groups for Enbrel users for experience-based advice and support in navigating insurance processes.

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FAQs

Does Harvard Pilgrim Health Care Cover Enbrel

Discover if Enbrel is covered by Harvard Pilgrim Health Care, understand potential denial reasons, costs without insurance, and how to secure coverage.

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Is Enbrel Covered by Harvard Pilgrim Health Care

Coverage of Enbrel

Harvard Pilgrim Health Care generally covers Enbrel for conditions like rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, and juvenile idiopathic arthritis.

Coverage is subject to prior authorization, ensuring that Enbrel is medically necessary for the patient's condition.

Criteria for Coverage

The patient must have failed to respond adequately to one or more DMARDs (Disease-Modifying Antirheumatic Drugs) before Enbrel is considered for coverage.

A detailed medical history and treatment plan must be provided by the healthcare provider to support the need for Enbrel.

Basic Rules

Coverage may vary based on the specific health plan and the tier classification of Enbrel in the formulary.

Patients may have to manage copayments or coinsurance, and the amount depends on their particular plan.

Regular updates and reviews ensure that the coverage criteria are aligned with current medical standards and guidelines.

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Harvard Pilgrim Health Care's Approved Criteria for Enbrel Coverage

Criteria for Enbrel Coverage under Harvard Pilgrim Health Care

Enbrel is approved for the treatment of moderate to severe rheumatoid arthritis in adults when prescribed by a rheumatologist. The patient must have attempted treatment with at least one other disease-modifying anti-rheumatic drug (DMARD) without adequate success.

Coverage includes patients with psoriatic arthritis who are 18 years or older, showing significant symptom improvement with Enbrel and are under the care of a licensed rheumatologist or dermatologist.

For the treatment of ankylosing spondylitis, Enbrel may be covered for adults who have failed non-steroidal anti-inflammatory drugs (NSAIDs) and demonstrate ongoing symptoms or inflammation markers.

Pediatric patients aged 4 years and older diagnosed with moderate to severe juvenile idiopathic arthritis (JIA) may be eligible for Enbrel coverage after trying at least two other treatment options recommended by a pediatric rheumatologist.

Patients with plaque psoriasis who are 18 years or older may receive coverage if the disease is classified as chronic, moderate-to-severe, covering more than 10% of the body surface area, and if they have not responded to topical therapies or phototherapy.

Enbrel is covered for patients diagnosed with non-infectious uveitis, provided there's documentation of previous treatment attempts with corticosteroids or immunosuppressants and ongoing monitoring by an ophthalmologist.

Pre-authorization from Harvard Pilgrim Health Care is required along with relevant medical records. Prescriptions need to be provided by a licensed healthcare professional authorized to prescribe within the specific field of the patient's condition.

Why Harvard Pilgrim Health Care Might Deny Enbrel Coverage

Situations Where Coverage for Enbrel May Be Denied

The patient's medical condition does not meet the FDA-approved indications for Enbrel, such as moderate to severe rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, or plaque psoriasis.

The patient has not completed a trial and failure, contraindication, or intolerance to preferred alternative therapies mandated by Harvard Pilgrim Health Care's formulary guidelines.

Enbrel is being requested for a use that is considered experimental, investigational, or not evidence-based according to Harvard Pilgrim Health Care's policy.

The patient does not meet the specific age or dosage restrictions outlined in the coverage policy, such as cases where Enbrel is not approved for pediatric use, depending on specific conditions.

The prescribing provider has not submitted necessary documentation or fails to provide adequate medical justification for the use of Enbrel over other formulary options.

The patient has not adhered to the required monitoring parameters or follow-up care as stipulated by Harvard Pilgrim Health Care for ongoing Enbrel treatment.

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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 Harvard Pilgrim Health Care

Contact Harvard Pilgrim Health Care Customer Service

Begin by calling Harvard Pilgrim's customer service number located on your member ID card. Inquire about coverage for Enbrel and any potential prerequisites or paperwork needed.

Ask for detailed information on your specific health plan, including any deductibles, copayments, or coinsurance that may apply to Enbrel.

Consult Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss the medical necessity of Enbrel. Ensure that the provider can provide any necessary documentation or letters of medical necessity.

Request your provider to check if a prior authorization is needed and if they can initiate the process on your behalf.

Locate the Prior Authorization Form

Visit the Harvard Pilgrim Health Care website and download the prior authorization form if your doctor hasn't already provided one.

Ensure all necessary personal and medical details are completed accurately on the form.

Submit the Prior Authorization Form

Have your healthcare provider submit the completed prior authorization form along with any support documentation to Harvard Pilgrim.

Ensure you or your healthcare provider follow up to confirm receipt and review any additional information needed for processing.

Review the Coverage Decision

Once the authorization is reviewed, Harvard Pilgrim will inform you of the decision. This may occur via mail or through an online patient portal.

If the request is approved, carefully review the details to understand any conditions or limitations to your coverage.

Explore Alternatives if Denied

If the initial decision is a denial, contact Harvard Pilgrim for specific reasons and inquire about the appeals process.

Work with your healthcare provider to gather additional supporting information to strengthen an appeal.

Stay Informed

Regularly check Harvard Pilgrim's formulary list and updates on Enbrel coverage since healthcare policies can change.

Consider joining patient support groups for Enbrel users for experience-based advice and support in navigating 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 Harvard Pilgrim Health Care Cover Enbrel

Discover if Enbrel is covered by Harvard Pilgrim Health Care, understand potential denial reasons, costs without insurance, and how to secure coverage.

Achieve Your Goals Faster with Curex