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Does Sharp Health Plan Cover Enbrel

Discover if Sharp Health Plan covers Enbrel. Learn denial reasons, how to secure coverage, cost without insurance, and explore FAQs.

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Coverage for Enbrel

Sharp Health Plan may cover Enbrel if it is medically necessary. Patients usually need a diagnosis of certain autoimmune conditions such as rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis.

Prior authorization is typically required to assess eligibility based on individual health needs and appropriateness of Enbrel therapy.

Criteria for Coverage

A prescribing doctor must provide documentation supporting the medical need and confirm that other treatments were ineffective or unsuitable.

Coverage may depend on the member's specific plan benefits, and some plans might have tiered coverage based on cost or generic options availability.

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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 Sharp Health Plan

Verify Your Eligibility

Before initiating coverage for Enbrel with Sharp Health Plan, confirm that your current plan offers prescription drug coverage. This can typically be found in your policy documents or by contacting customer service.

Ensure Enbrel is included in the formulary of covered drugs. Check the Sharp Health Plan website or call their customer service for information on their drug formulary.

Consult with Your Healthcare Provider

Discuss with your healthcare provider to ensure Enbrel is medically necessary for your condition. Your healthcare provider may need to provide documentation or evidence to support its necessity.

Obtain a prescription for Enbrel if medically appropriate.

Gather Necessary Documentation

Collect any required documents for the authorization process, which may include your Sharp Health Plan membership information and medical records related to your condition.

Ensure you have your healthcare provider's contact information available, as this might be needed during the process.

Contact Sharp Health Plan

Reach out to Sharp Health Plan customer service. Enquire specifically about the process for obtaining pre-authorization for Enbrel under your current plan.

Request the necessary forms for prior authorization, if applicable.

Submit a Prior Authorization Request

Complete the prior authorization form with assistance from your healthcare provider. This form may need to include your medical history, diagnosis, and rationale for why Enbrel is necessary.

Submit the completed form along with any required medical documentation to Sharp Health Plan. Ensure all fields are filled accurately to avoid delays.

Follow Up with Sharp Health Plan

After submission, follow up with Sharp Health Plan to confirm receipt of your prior authorization request. Ask about the expected timeline for processing.

Maintain open communication with your healthcare provider in case additional information or documentation is needed.

Receive Coverage Decision

Wait for a response from Sharp Health Plan regarding approval or denial of coverage for Enbrel. This will typically be communicated through a letter or a phone call.

If approved, review the terms, including any copayments, deductibles, or limitations associated with Enbrel coverage.

If denied, inquire about the reasons for denial and the appeals process. You may need your healthcare provider's assistance to provide further justification or additional documentation for appeal.

Procure Enbrel Prescription

If authorized, coordinate with your pharmacy to fill the Enbrel prescription. Provide them with any necessary authorization details.

Verify with the pharmacy that coverage is applied correctly, and ask about any copayments or out-of-pocket costs you might incur.

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Does Sharp Health Plan Cover Enbrel

Discover if Sharp Health Plan covers Enbrel. Learn denial reasons, how to secure coverage, cost without insurance, and explore FAQs.

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Is Enbrel Covered by Sharp Health Plan

Coverage for Enbrel

Sharp Health Plan may cover Enbrel if it is medically necessary. Patients usually need a diagnosis of certain autoimmune conditions such as rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis.

Prior authorization is typically required to assess eligibility based on individual health needs and appropriateness of Enbrel therapy.

Criteria for Coverage

A prescribing doctor must provide documentation supporting the medical need and confirm that other treatments were ineffective or unsuitable.

Coverage may depend on the member's specific plan benefits, and some plans might have tiered coverage based on cost or generic options availability.

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Sharp Health Plan's Approved Criteria for Enbrel Coverage

Approved Criteria for Enbrel Coverage

**Diagnosis Requirement:** The patient must have a confirmed diagnosis of one of the following conditions: - Rheumatoid Arthritis - Plaque Psoriasis - Psoriatic Arthritis - Ankylosing Spondylitis - Polyarticular Juvenile Idiopathic Arthritis

**Prescribing Information:** Enbrel should be prescribed by a healthcare provider specializing in the treatment of the relevant condition. This usually includes rheumatologists, dermatologists, or relevant specialists.

**Previous Treatment:** The patient should have tried and failed a trial of at least one disease-modifying anti-rheumatic drug (DMARD) or other systemic therapy appropriate to the condition being treated. Documentation of ineffectiveness or intolerance to these medications is required.

**Dosage and Administration:** The dosage and administration of Enbrel must align with FDA recommendations and be appropriate for the patient’s age, weight, and condition as outlined in the prescribing information.

**Patient Monitoring and Safety:** Regular monitoring of the patient's response to therapy is required, along with vigilance for potential side effects. Appropriate lab tests and examinations should be part of the treatment plan.

**Insurance Plan Mandates:** The coverage is contingent upon the terms and conditions of the specific Sharp Health Plan insurance policy held by the patient, including applicable co-pays, deductibles, and prior authorization requirements.

**Age Requirement:** For certain conditions, Enbrel is approved for use in patients ages 2 and older. The prescribing physician must ensure the patient meets age requirements stipulated for the specific condition.

**Continuation of Therapy:** For ongoing coverage, documentation must show sustained effectiveness of Enbrel in treating the specific condition. Periodic reauthorization and consultation with the prescribing specialist may be required.

**Use in Combination Therapy:** Coverage includes the use of Enbrel as a standalone treatment or in combination with other DMARDs, as long as it is deemed suitable by the treating physician and aligns with best clinical practices.

Why Sharp Health Plan Might Deny Enbrel Coverage

Reasons for Denial of Enbrel Coverage by Sharp Health Plan

**Non-FDA Approved Indications**: Enbrel is not covered for conditions that are not approved by the Food and Drug Administration (FDA).

**Lack of Medical Necessity**: If Enbrel is not deemed medically necessary based on the patient's diagnosis and condition, coverage may be denied.

**Failure to Meet Prior Authorization Requirements**: Enbrel must have prior authorization, and if the required documentation or steps are not completed, coverage can be denied.

**Generic Alternatives Available**: If there's a generic alternative that's considered as effective and safe as Enbrel, coverage for Enbrel might be denied.

**Non-Compliance with Step Therapy Protocols**: Sharp Health Plan may require other treatments to be tried and failed before approving Enbrel. Failing to follow these protocols can lead to denial.

**Plan Exclusions**: Some health plans may have specific exclusions that prevent coverage of biologic drugs like Enbrel.

**Out-of-Network Prescriptions**: Coverage may be denied if Enbrel is prescribed by an out-of-network provider when an in-network option is available.

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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 Sharp Health Plan

Verify Your Eligibility

Before initiating coverage for Enbrel with Sharp Health Plan, confirm that your current plan offers prescription drug coverage. This can typically be found in your policy documents or by contacting customer service.

Ensure Enbrel is included in the formulary of covered drugs. Check the Sharp Health Plan website or call their customer service for information on their drug formulary.

Consult with Your Healthcare Provider

Discuss with your healthcare provider to ensure Enbrel is medically necessary for your condition. Your healthcare provider may need to provide documentation or evidence to support its necessity.

Obtain a prescription for Enbrel if medically appropriate.

Gather Necessary Documentation

Collect any required documents for the authorization process, which may include your Sharp Health Plan membership information and medical records related to your condition.

Ensure you have your healthcare provider's contact information available, as this might be needed during the process.

Contact Sharp Health Plan

Reach out to Sharp Health Plan customer service. Enquire specifically about the process for obtaining pre-authorization for Enbrel under your current plan.

Request the necessary forms for prior authorization, if applicable.

Submit a Prior Authorization Request

Complete the prior authorization form with assistance from your healthcare provider. This form may need to include your medical history, diagnosis, and rationale for why Enbrel is necessary.

Submit the completed form along with any required medical documentation to Sharp Health Plan. Ensure all fields are filled accurately to avoid delays.

Follow Up with Sharp Health Plan

After submission, follow up with Sharp Health Plan to confirm receipt of your prior authorization request. Ask about the expected timeline for processing.

Maintain open communication with your healthcare provider in case additional information or documentation is needed.

Receive Coverage Decision

Wait for a response from Sharp Health Plan regarding approval or denial of coverage for Enbrel. This will typically be communicated through a letter or a phone call.

If approved, review the terms, including any copayments, deductibles, or limitations associated with Enbrel coverage.

If denied, inquire about the reasons for denial and the appeals process. You may need your healthcare provider's assistance to provide further justification or additional documentation for appeal.

Procure Enbrel Prescription

If authorized, coordinate with your pharmacy to fill the Enbrel prescription. Provide them with any necessary authorization details.

Verify with the pharmacy that coverage is applied correctly, and ask about any copayments or out-of-pocket costs you might incur.

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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 Sharp Health Plan Cover Enbrel

Discover if Sharp Health Plan covers Enbrel. Learn denial reasons, how to secure coverage, cost without insurance, and explore FAQs.

Achieve Your Goals Faster with Curex