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Does Network Health Cover Enbrel

Explore if Network Health covers Enbrel, understand reasons for denial, learn how to secure coverage, discover costs without insurance, and get answers in our FAQs.

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Enbrel Coverage Overview

Network Health typically covers Enbrel for patients diagnosed with specific conditions such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.

Coverage may require prior authorization, ensuring that the medication is necessary and aligned with treatment guidelines.

Criteria for Coverage

The patient needs a documented diagnosis of a qualifying condition by a healthcare provider.

Treatment must be deemed medically necessary as evaluated by a healthcare professional.

Proof of unsuccessful response to other preferred treatment options may be required before Enbrel is approved.

Basic Rules and Steps

Contact Network Health for detailed information on specific coverage rules and prerequisites.

Ensure all required documentation and medical records are prepared for the authorization request.

Confirm network pharmacy involvement to minimize out-of-pocket costs when filling the prescription.

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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

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 Network Health

Initial Steps with Network Health

Start by verifying that your current health plan with Network Health covers prescription medications, and check if Enbrel is listed under the formulary or covered medications.

Ensure that you are eligible for coverage with Network Health by reviewing their membership requirements and confirming your enrollment status.

Consult with Healthcare Provider

Discuss with your doctor about the need for Enbrel and obtain any necessary documentation or letters of medical necessity that might be required by Network Health.

Ensure your healthcare provider is within the Network Health network, as this can affect pre-authorization and coverage.

Verify Prescription Coverage

Contact Network Health directly by calling their customer service number. Ask specifically about the coverage details for Enbrel, including any co-payments, deductibles, or prior authorization requirements.

Utilize the Network Health member portal, if available, to check the detailed benefits and coverage specifics related to specialty drugs like Enbrel.

Complete Pre-Authorization (if required)

If pre-authorization is needed for Enbrel, work with your healthcare provider to submit the necessary pre-authorization forms to Network Health. Ensure completeness and accuracy to avoid delays.

Track the status of your pre-authorization request through Network Health's customer service or member portal to ensure timely approval.

Filing a Prescription Claim

Once your prescription for Enbrel has been approved, your healthcare provider will likely send the prescription directly to a pharmacy that operates within Network Health’s network.

Ensure that you choose an in-network pharmacy for filling your prescription to minimize out-of-pocket costs. Confirm that your Enbrel prescription has been processed correctly by checking your benefits statement.

Appeal Decisions (if necessary)

If Network Health denies coverage for Enbrel, review the denial letter carefully to understand the reasons. You have the right to appeal this decision.

Submit a formal appeal with any additional supporting information from your healthcare provider, emphasizing the medical necessity of Enbrel for your condition.

Explore Additional Assistance Programs

Investigate if there are any patient assistance programs offered by the manufacturer of Enbrel or third-party organizations, which can help reduce costs not covered by insurance.

Consult with a Network Health representative for suggestions on available programs or alternatives that can assist with medication costs.

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FAQs

Does Network Health Cover Enbrel

Explore if Network Health covers Enbrel, understand reasons for denial, learn how to secure coverage, discover costs without insurance, and get answers in our FAQs.

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Is Enbrel Covered by Network Health

Enbrel Coverage Overview

Network Health typically covers Enbrel for patients diagnosed with specific conditions such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.

Coverage may require prior authorization, ensuring that the medication is necessary and aligned with treatment guidelines.

Criteria for Coverage

The patient needs a documented diagnosis of a qualifying condition by a healthcare provider.

Treatment must be deemed medically necessary as evaluated by a healthcare professional.

Proof of unsuccessful response to other preferred treatment options may be required before Enbrel is approved.

Basic Rules and Steps

Contact Network Health for detailed information on specific coverage rules and prerequisites.

Ensure all required documentation and medical records are prepared for the authorization request.

Confirm network pharmacy involvement to minimize out-of-pocket costs when filling the prescription.

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Network Health's Approved Criteria for Enbrel Coverage

Covered Indications for Enbrel

Enbrel (etanercept) is covered for the treatment of moderate to severe rheumatoid arthritis in adult patients who have had an inadequate response to one or more disease-modifying anti-rheumatic drugs (DMARDs).

Enbrel is approved for the treatment of polyarticular juvenile idiopathic arthritis in patients aged 2 years and older.

Coverage is provided for adult patients with moderate to severe psoriatic arthritis, either alone or in combination with methotrexate.

Enbrel is covered for reducing signs and symptoms of active ankylosing spondylitis in adults who have inadequate response to conventional therapies.

Approved for the treatment of chronic moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy.

Requirements for Prior Authorization

Must include a documented diagnosis from a healthcare provider specifying one of the conditions for which Enbrel is covered.

Documentation of previous therapies and a description of inadequate response to those, especially DMARDs, is necessary for rheumatoid arthritis.

Submission of baseline assessment of disease severity using established criteria, such as tender and swollen joint counts for rheumatoid or psoriatic arthritis.

Confirmation that Enbrel is used as part of a comprehensive treatment plan, potentially including education, physiotherapy, or combination therapy where appropriate.

Enrollment in Network Health's disease management program may be required to ensure ongoing assessment and adherence to treatment protocols.

Renewal Criteria

Evidence of clinical improvement or stabilization of the disease condition as part of the periodic review.

Compliance with treatment as evidenced by pharmacy refill data and healthcare provider assessments.

No serious adverse effects associated with Enbrel that would contraindicate its continued use.

Verified continuous compliance with the disease management program.

Continued critical evaluation to ensure the medication is providing meaningful benefit over potential risks.

Why Network Health Might Deny Enbrel Coverage

Situations When Enbrel Coverage is Denied

Enbrel is prescribed for a condition that is not FDA-approved or not supported by accepted clinical guidelines.

The patient has not met the required step therapy protocols, such as trying and failing less expensive medications first.

No prior authorization has been obtained before the initiation of treatment with Enbrel, if it is mandated by the policy.

The prescription is considered off-label use without sufficient clinical evidence or medical necessity documentation.

Coverage is sought for a purpose explicitly excluded by the insurance policy, like cosmetic use or non-medical purposes.

The prescribed treatment plan does not align with the network's defined dosage and treatment duration guidelines for Enbrel.

There is insufficient documentation or records provided to justify the medical necessity of Enbrel therapy.

The patient is using Enbrel concurrently with other medications in a manner that the policy does not cover due to potential interactions or safety concerns.

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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 Network Health

Initial Steps with Network Health

Start by verifying that your current health plan with Network Health covers prescription medications, and check if Enbrel is listed under the formulary or covered medications.

Ensure that you are eligible for coverage with Network Health by reviewing their membership requirements and confirming your enrollment status.

Consult with Healthcare Provider

Discuss with your doctor about the need for Enbrel and obtain any necessary documentation or letters of medical necessity that might be required by Network Health.

Ensure your healthcare provider is within the Network Health network, as this can affect pre-authorization and coverage.

Verify Prescription Coverage

Contact Network Health directly by calling their customer service number. Ask specifically about the coverage details for Enbrel, including any co-payments, deductibles, or prior authorization requirements.

Utilize the Network Health member portal, if available, to check the detailed benefits and coverage specifics related to specialty drugs like Enbrel.

Complete Pre-Authorization (if required)

If pre-authorization is needed for Enbrel, work with your healthcare provider to submit the necessary pre-authorization forms to Network Health. Ensure completeness and accuracy to avoid delays.

Track the status of your pre-authorization request through Network Health's customer service or member portal to ensure timely approval.

Filing a Prescription Claim

Once your prescription for Enbrel has been approved, your healthcare provider will likely send the prescription directly to a pharmacy that operates within Network Health’s network.

Ensure that you choose an in-network pharmacy for filling your prescription to minimize out-of-pocket costs. Confirm that your Enbrel prescription has been processed correctly by checking your benefits statement.

Appeal Decisions (if necessary)

If Network Health denies coverage for Enbrel, review the denial letter carefully to understand the reasons. You have the right to appeal this decision.

Submit a formal appeal with any additional supporting information from your healthcare provider, emphasizing the medical necessity of Enbrel for your condition.

Explore Additional Assistance Programs

Investigate if there are any patient assistance programs offered by the manufacturer of Enbrel or third-party organizations, which can help reduce costs not covered by insurance.

Consult with a Network Health representative for suggestions on available programs or alternatives that can assist with medication costs.

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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 Network Health Cover Enbrel

Explore if Network Health covers Enbrel, understand reasons for denial, learn how to secure coverage, discover costs without insurance, and get answers in our FAQs.

Achieve Your Goals Faster with Curex