Does Highmark Cover Enbrel

Explore Highmark's Enbrel coverage. Learn reasons for denial, how to secure coverage, cost details without insurance, and find answers to common questions.
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Does Highmark Cover Enbrel?

 

  • Highmark does cover Enbrel for approved conditions such as rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, and ankylosing spondylitis. Coverage may vary based on your specific Highmark plan.
  •  

  • Prior authorization is usually required to approve coverage of Enbrel, ensuring medical necessity based on the prescribed health condition.
  •  

  • Patients must meet specific criteria, like trying and failing other preferred treatments, and must also demonstrate the severity of the condition to qualify for Enbrel.
  •  

  • It is essential to verify the coverage specifics with Highmark directly, as plan benefits, policies, and criteria can vary and change.

 

Steps to Obtain Coverage

 

  • Consult with your healthcare provider to determine if Enbrel is the appropriate treatment for your condition.
  •  

  • Submit a prior authorization request through your healthcare provider, including necessary documentation to support the medical necessity of Enbrel.
  •  

  • Contact Highmark's customer service for any assistance or to confirm specific coverage details related to your plan.

 

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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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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 Highmark

 

Gather Necessary Documentation

 

  • Obtain a comprehensive prescription for Enbrel from your doctor detailing your medical necessity.
  •  

  • Collect relevant medical history and records, showing a history of conditions such as rheumatoid arthritis that Enbrel is used to treat.
  •  

  • Ensure you have the most recent insurance ID card from Highmark, as you'll need your policy number and group number.

 

Contact Highmark Customer Service

 

  • Call the number located on the back of your insurance card. A representative can guide you through the specifics of your coverage plan and discuss the procedures for getting prescription drugs like Enbrel covered.
  •  

  • Inquire specifically about the formulary status of Enbrel, to ensure it’s included in the covered drugs list.

 

Consult Your Doctor to Prepare a Prior Authorization (PA)

 

  • Have your healthcare provider submit a Prior Authorization request to Highmark on your behalf. This process helps explain why Enbrel is necessary for your treatment.
  •  

  • Ensure that your physician provides all necessary documentation, demonstrating that alternative treatments have been unsuccessful or are inappropriate.

 

Check Eligibility for Any Available Assistance Programs

 

  • Research if there are manufacturer discount programs or patient assistance options available for Enbrel that Highmark might participate in.
  •  

  • Contact Enbrel support lines or visit their official website to see if you can reduce out-of-pocket expenses via any financial assistance programs.

 

Review Your Plan’s Cost Sharing Requirements

 

  • Understand your deductible, copay, and coinsurance amounts for Tier 1, 2, or 3 medications to gauge what your out-of-pocket costs could be.
  •  

  • Verify if there are specific pharmacies that need to be used for better pricing or full coverage of Enbrel.

 

Submit the Claim and Documentation

 

  • Once you receive prior authorization approval, ensure you or your doctor submits the claim correctly, with all necessary documents attached.
  •  

  • Work with your doctor’s office and pharmacy to verify that the prescription is valid and fulfillable under your Highmark plan.

 

Follow Up on the Claim’s Status

 

  • After submitting the claim, consistently check the status through Highmark’s member portal or by calling customer service directly.
  •  

  • Address any issues or rejections promptly by providing more documentation or clarifying any discrepancies that may have occurred during the review process.

 

Regular Verification and Updates

 

  • Schedule periodic reviews with Highmark to track any changes in the coverage terms that may affect Enbrel’s cost or availability.
  •  

  • Stay informed about any changes to your health insurance plan during open enrollment periods, as these might impact your drug coverage terms.

 

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FAQs

Does Highmark Cover Enbrel

Explore Highmark's Enbrel coverage. Learn reasons for denial, how to secure coverage, cost details without insurance, and find answers to common questions.
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Is Enbrel Covered by Highmark

 

Does Highmark Cover Enbrel?

 

  • Highmark does cover Enbrel for approved conditions such as rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, and ankylosing spondylitis. Coverage may vary based on your specific Highmark plan.
  •  

  • Prior authorization is usually required to approve coverage of Enbrel, ensuring medical necessity based on the prescribed health condition.
  •  

  • Patients must meet specific criteria, like trying and failing other preferred treatments, and must also demonstrate the severity of the condition to qualify for Enbrel.
  •  

  • It is essential to verify the coverage specifics with Highmark directly, as plan benefits, policies, and criteria can vary and change.

 

Steps to Obtain Coverage

 

  • Consult with your healthcare provider to determine if Enbrel is the appropriate treatment for your condition.
  •  

  • Submit a prior authorization request through your healthcare provider, including necessary documentation to support the medical necessity of Enbrel.
  •  

  • Contact Highmark's customer service for any assistance or to confirm specific coverage details related to your plan.

 

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Highmark's Approved Criteria for Enbrel Coverage

 

Coverage Criteria for Psoriatic Arthritis

 

  • Treatment of active psoriatic arthritis in individuals who have tried and failed conventional medications such as non-steroidal anti-inflammatory drugs (NSAIDs) or disease-modifying anti-rheumatic drugs (DMARDs).
  • Diagnosed by a healthcare professional with documented symptoms and a prescription for Enbrel.

 

Coverage Criteria for Rheumatoid Arthritis

 

  • Indicated for patients with moderate to severe rheumatoid arthritis. Must have documented failure or intolerance to a trial of first-line therapies including at least one DMARD.
  • Evaluated and diagnosed by a healthcare provider specializing in rheumatology.

 

Coverage Criteria for Ankylosing Spondylitis

 

  • Approved for individuals with active ankylosing spondylitis who have had an inadequate response to conventional treatments.
  • Diagnosis must be confirmed by a rheumatologist with supporting clinical and radiographic evidence.

 

Coverage Criteria for Juvenile Idiopathic Arthritis (JIA)

 

  • Coverage is applicable for children aged 2 and above with moderate to severe polyarticular JIA.
  • Requirement includes documented trial and failure of one or more DMARDs, verified by a pediatric rheumatologist.

 

Coverage Criteria for Plaque Psoriasis

 

  • Enbrel is approved for patients 18 years or older with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.
  • Condition must be diagnosed by a dermatologist and documented with a history of treatment attempts.

 

Why Highmark Might Deny Enbrel Coverage

 

Situations Where Enbrel Coverage May Be Denied by Highmark

 

  • If Enbrel is prescribed for conditions not listed in Highmark's approved usage guidelines or formularies.
  •  

  • In cases where a patient has not tried and failed other preferred medications before opting for Enbrel, if required by Highmark's step therapy protocols.
  •  

  • If the request for Enbrel exceeds the dosage or quantity limits set by Highmark's policies without appropriate medical justification.
  •  

  • When Enbrel is prescribed for off-label uses that are not supported by clinical evidence reviewed by Highmark's policy team.
  •  

  • For patients who do not meet the specific clinical criteria outlined by Highmark, such as age restrictions or necessary accompanying conditions.
  •  

  • In scenarios where Enbrel is sought for a duration longer than covered under Highmark's policy without submitting required documentation for medical necessity.
  •  

  • When proper documentation and pre-authorization requests are not correctly submitted or completed as per Highmark's procedure guidelines.

 

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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.

 

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 Highmark

 

Gather Necessary Documentation

 

  • Obtain a comprehensive prescription for Enbrel from your doctor detailing your medical necessity.
  •  

  • Collect relevant medical history and records, showing a history of conditions such as rheumatoid arthritis that Enbrel is used to treat.
  •  

  • Ensure you have the most recent insurance ID card from Highmark, as you'll need your policy number and group number.

 

Contact Highmark Customer Service

 

  • Call the number located on the back of your insurance card. A representative can guide you through the specifics of your coverage plan and discuss the procedures for getting prescription drugs like Enbrel covered.
  •  

  • Inquire specifically about the formulary status of Enbrel, to ensure it’s included in the covered drugs list.

 

Consult Your Doctor to Prepare a Prior Authorization (PA)

 

  • Have your healthcare provider submit a Prior Authorization request to Highmark on your behalf. This process helps explain why Enbrel is necessary for your treatment.
  •  

  • Ensure that your physician provides all necessary documentation, demonstrating that alternative treatments have been unsuccessful or are inappropriate.

 

Check Eligibility for Any Available Assistance Programs

 

  • Research if there are manufacturer discount programs or patient assistance options available for Enbrel that Highmark might participate in.
  •  

  • Contact Enbrel support lines or visit their official website to see if you can reduce out-of-pocket expenses via any financial assistance programs.

 

Review Your Plan’s Cost Sharing Requirements

 

  • Understand your deductible, copay, and coinsurance amounts for Tier 1, 2, or 3 medications to gauge what your out-of-pocket costs could be.
  •  

  • Verify if there are specific pharmacies that need to be used for better pricing or full coverage of Enbrel.

 

Submit the Claim and Documentation

 

  • Once you receive prior authorization approval, ensure you or your doctor submits the claim correctly, with all necessary documents attached.
  •  

  • Work with your doctor’s office and pharmacy to verify that the prescription is valid and fulfillable under your Highmark plan.

 

Follow Up on the Claim’s Status

 

  • After submitting the claim, consistently check the status through Highmark’s member portal or by calling customer service directly.
  •  

  • Address any issues or rejections promptly by providing more documentation or clarifying any discrepancies that may have occurred during the review process.

 

Regular Verification and Updates

 

  • Schedule periodic reviews with Highmark to track any changes in the coverage terms that may affect Enbrel’s cost or availability.
  •  

  • Stay informed about any changes to your health insurance plan during open enrollment periods, as these might impact your drug coverage terms.

 

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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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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.

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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.

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