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Does Sharp Health Plan Cover Orencia

Explore coverage options for Orencia under Sharp Health Plan, pricing without insurance, and strategies to secure coverage. Get answers to common questions.

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Sharp Health Plan Coverage for Orencia

Sharp Health Plan provides coverage for Orencia (abatacept) under certain circumstances. Orencia is typically used to treat autoimmune conditions such as rheumatoid arthritis.

To be eligible for coverage, patients must generally have a confirmed diagnosis that aligns with Orencia's approved uses, such as moderate to severe rheumatoid arthritis or psoriatic arthritis.

Usually, patients must have tried and not responded adequately to other disease-modifying antirheumatic drugs (DMARDs) before Orencia is approved.

Prior authorization from Sharp Health Plan is usually required, which involves a review of the patient's medical records and a recommendation from the healthcare provider.

Coverage may depend on the specific plan details, so reviewing your policy or contacting Sharp Health Plan directly for confirmation and specific criteria is essential.

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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 Orencia Coverage with Sharp Health Plan

Verify Your Eligibility

Contact Sharp Health Plan customer service to confirm that you are eligible for Orencia coverage under your existing health plan.

Review your policy documents to understand specific coverage details related to Orencia, including any prior authorizations or specialist referrals required.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss the medical necessity for Orencia and to obtain a prescription if it's deemed appropriate for your condition.

Request your provider to submit the prescription along with necessary documentation of your medical history to Sharp Health Plan or directly to the pharmacy benefit manager handling Orencia.

Obtain Prior Authorization

Work with your healthcare provider to submit a prior authorization request to Sharp Health Plan. This may include completing specific forms and providing detailed medical records that justify the use of Orencia.

Follow up with Sharp Health Plan to ensure the authorization request is processed and approved in a timely manner.

Understand Your Costs and Coverage Terms

Review the coverage terms provided by Sharp Health Plan, including co-pays, co-insurance, or any deductible that may apply to Orencia treatment.

Check if there are any specific pharmacies within the network that must be used to obtain Orencia to ensure coverage.

Fill Your Prescription

Take your prescription to a preferred pharmacy as indicated by Sharp Health Plan, ensuring they are aware of your coverage and prior authorization approval.

Coordinate with your pharmacy to address any issues that may arise during the prescription filling process, such as verification of benefits or delays in dispensing.

Appeal if Necessary

If your coverage request for Orencia is denied, work with your healthcare provider to gather additional information or documentation that supports the medical necessity of Orencia for your condition.

Submit an appeal to Sharp Health Plan following their established procedures, and provide any supplementary information or clarification needed to facilitate approval.

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Does Sharp Health Plan Cover Orencia

Explore coverage options for Orencia under Sharp Health Plan, pricing without insurance, and strategies to secure coverage. Get answers to common questions.

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Is Orencia Covered by Sharp Health Plan

Sharp Health Plan Coverage for Orencia

Sharp Health Plan provides coverage for Orencia (abatacept) under certain circumstances. Orencia is typically used to treat autoimmune conditions such as rheumatoid arthritis.

To be eligible for coverage, patients must generally have a confirmed diagnosis that aligns with Orencia's approved uses, such as moderate to severe rheumatoid arthritis or psoriatic arthritis.

Usually, patients must have tried and not responded adequately to other disease-modifying antirheumatic drugs (DMARDs) before Orencia is approved.

Prior authorization from Sharp Health Plan is usually required, which involves a review of the patient's medical records and a recommendation from the healthcare provider.

Coverage may depend on the specific plan details, so reviewing your policy or contacting Sharp Health Plan directly for confirmation and specific criteria is essential.

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Sharp Health Plan's Approved Criteria for Orencia Coverage

Criteria for Orencia Coverage under Sharp Health Plan

The patient must have a confirmed diagnosis of moderate to severe rheumatoid arthritis, juvenile idiopathic arthritis, or psoriatic arthritis.

Orencia is prescribed by or in consultation with a rheumatologist or a specialist in the treatment of the condition.

The patient must have documented evidence of inadequate response, intolerance, or contraindication to at least one traditional disease-modifying anti-rheumatic drug (DMARD) therapy.

For patients with juvenile idiopathic arthritis, Orencia is approved if used in children ages 2 and older as a monotherapy or in combination with methotrexate.

For patients with psoriatic arthritis, Orencia is covered when there is documented failure of at least one tumor necrosis factor (TNF) inhibitor, unless contraindicated or not tolerated.

The patient's body weight is suitable for Orencia, particularly in cases where the intravenous form is used.

The patient has demonstrated compliance with previous treatment regimens and follow-up requirements.

Continuous treatment with Orencia is subject to periodic re-evaluation, and continuation is dependent on documentation of ongoing benefit from therapy.

Why Sharp Health Plan Might Deny Orencia Coverage

Reasons for Orencia Coverage Denial

Orencia is not prescribed for an approved indication as per Sharp Health Plan's guidelines.

The patient does not meet the specific medical criteria established by Sharp Health Plan for Orencia eligibility.

Lack of documentation supporting the medical necessity of Orencia for the patient.

The patient has not tried or failed other preferred treatment options covered by Sharp Health Plan before Orencia.

Orencia is requested for a non-FDA-approved use without sufficient evidence or peer-reviewed publications supporting its use for that condition.

The request for Orencia exceeds the dosage limits set by Sharp Health Plan without adequate justification.

The patient's insurance plan specifically excludes Orencia as a covered benefit.

The prescribing provider is not within the Sharp Health Plan's network and no prior authorization for out-of-network service has been obtained.

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How Much Does Orencia Cost without Insurance?

Cost of Orencia Without Insurance

The approximate cost for Orencia, when paying out of pocket without insurance, is between $4,500 to $5,000 per month. This cost can vary based on dosage, form (whether it's an IV infusion or subcutaneous injection), and the pharmacy or healthcare provider dispensing the medication.

Some patients may require different dosages which can further influence the cost, typically leading to higher expenses if more medication is required.

Patients without insurance may be eligible for manufacturer discounts or assistance programs, which can provide significant cost reductions. These programs often have specific eligibility requirements based on income and other factors.

Pharmacy discount cards or online services might offer slightly lower prices than traditional pharmacies.

Comparing costs between pharmacies and considering mail-order options can also help in reducing the overall expense.

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 Orencia Coverage with Sharp Health Plan

Verify Your Eligibility

Contact Sharp Health Plan customer service to confirm that you are eligible for Orencia coverage under your existing health plan.

Review your policy documents to understand specific coverage details related to Orencia, including any prior authorizations or specialist referrals required.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss the medical necessity for Orencia and to obtain a prescription if it's deemed appropriate for your condition.

Request your provider to submit the prescription along with necessary documentation of your medical history to Sharp Health Plan or directly to the pharmacy benefit manager handling Orencia.

Obtain Prior Authorization

Work with your healthcare provider to submit a prior authorization request to Sharp Health Plan. This may include completing specific forms and providing detailed medical records that justify the use of Orencia.

Follow up with Sharp Health Plan to ensure the authorization request is processed and approved in a timely manner.

Understand Your Costs and Coverage Terms

Review the coverage terms provided by Sharp Health Plan, including co-pays, co-insurance, or any deductible that may apply to Orencia treatment.

Check if there are any specific pharmacies within the network that must be used to obtain Orencia to ensure coverage.

Fill Your Prescription

Take your prescription to a preferred pharmacy as indicated by Sharp Health Plan, ensuring they are aware of your coverage and prior authorization approval.

Coordinate with your pharmacy to address any issues that may arise during the prescription filling process, such as verification of benefits or delays in dispensing.

Appeal if Necessary

If your coverage request for Orencia is denied, work with your healthcare provider to gather additional information or documentation that supports the medical necessity of Orencia for your condition.

Submit an appeal to Sharp Health Plan following their established procedures, and provide any supplementary information or clarification needed to facilitate approval.

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Orencia FAQ

What are the common side effects of Orencia?

Common Side Effects of Orencia

**Infections:** Increased risk of upper respiratory infections, such as colds or sinus infections.

**Headache:** Mild to moderate headaches are commonly reported.

**Nausea:** Some patients may experience feelings of nausea.

**Fatigue:** Feeling unusually tired or weak can occur as well.

**Cough:** A persistent cough may develop during treatment.

**Pain:** Injection site reactions like redness or discomfort are possible.

How does Orencia work in treating rheumatoid arthritis?

How Orencia Works

Orencia is a biologic medication that targets specific components of the immune system to reduce inflammation in rheumatoid arthritis.

It works by binding to CD80/CD86 receptors on antigen-presenting cells, preventing the activation of T-cells, which play a critical role in the autoimmune response.

By inhibiting T-cell activation, Orencia helps decrease the inflammation and joint damage caused by rheumatoid arthritis.

Orencia is administered through injection, and its efficacy may take several weeks to become noticeable.

Benefits of Orencia

Reduces pain and swelling in affected joints, improving physical function.
Lowers the progression of joint damage over time.
Improves overall quality of life for patients with rheumatoid arthritis.

Is Orencia considered a biologic medication?

Orencia Overview

Orencia (abatacept) is classified as a biologic medication, used primarily to treat autoimmune conditions like rheumatoid arthritis.

Biologic Nature

It is a fusion protein that inhibits T-cell activation, an essential part of the immune response, thereby reducing inflammation.

Mechanism of Action

By blocking the co-stimulatory signal required for full T-cell activation, Orencia helps decrease abnormal immune responses involved in autoimmune diseases.

Administration and Use

Orencia is administered via intravenous infusion or subcutaneous injection, typically in a clinical setting.

Considerations

Patients should discuss potential benefits and risks with a healthcare professional, as Orencia may affect the immune system and increase the risk of infections.

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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 Orencia

Explore coverage options for Orencia under Sharp Health Plan, pricing without insurance, and strategies to secure coverage. Get answers to common questions.

Achieve Your Goals Faster with Curex