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Does Tufts Health Plan Cover Cosentyx

Find out if Tufts Health Plan covers Cosentyx, potential coverage obstacles, tips to secure coverage, cost without insurance, and answers to common questions.

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Tufts Health Plan Coverage for Cosentyx

**Criteria:** Coverage often requires proof of diagnosis for conditions like plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis.

**Documentation:** Submission of prior authorization is necessary, detailing medical necessity based on Tufts' guidelines.

**Treatment History:** Evidence of prior unsuccessful treatments with alternative therapies may be required.

**Provider Requirements:** Coverage may stipulate that prescriptions come from network providers and pharmacies.

**Renewal:** Periodic re-evaluation of medical necessity is required for continued coverage.

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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.

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 Cosentyx Coverage with Tufts Health Plan

Check Your Plan Benefits

Access your Tufts Health Plan member portal online to review your specific benefits.
Look for prescription drug coverage details to see if Cosentyx is listed or inquire about specialty medications.
Contact Tufts Health Plan customer service for clarification on your current plan's coverage for Cosentyx.

Consult Your Healthcare Provider

Discuss your treatment options with your healthcare provider and express interest in starting Cosentyx.
Ask your healthcare provider if they are aware of Tufts Health Plan requirements for Cosentyx coverage.
Obtain a prescription for Cosentyx if your healthcare provider agrees it's appropriate for your treatment.

Submit a Prior Authorization Request

Your healthcare provider should submit a prior authorization request to Tufts Health Plan on your behalf.
Ensure the request includes all necessary documentation, such as medical necessity and any past treatments you've tried.
Follow up with your healthcare provider to verify that the request has been submitted and received by Tufts Health Plan.

Contact Specialty Pharmacy

If you have been approved, Tufts Health Plan will likely direct you to a specialty pharmacy to receive Cosentyx.
Coordinate with the specialty pharmacy to arrange shipment of your medication as per your prescription schedule.
Ask about any potential co-pay assistance or programs for which you may be eligible through the pharmacy or Cosentyx manufacturer.

Appeal if Necessary

If your initial request for Cosentyx coverage is denied, review the denial letter for specific reasons provided by Tufts Health Plan.
Work with your healthcare provider to gather additional supporting documentation or to adjust the prior authorization request.
Submit an appeal following the instructions provided in the denial letter and keep in touch with Tufts Health Plan for updates.

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Potential for results in as few as 6 months

Individual results vary but some users have reported a noticeable difference in as few as 6-12 months since starting treatments

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FAQs

Does Tufts Health Plan Cover Cosentyx

Find out if Tufts Health Plan covers Cosentyx, potential coverage obstacles, tips to secure coverage, cost without insurance, and answers to common questions.

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Is Cosentyx Covered by Tufts Health Plan

Tufts Health Plan Coverage for Cosentyx

**Criteria:** Coverage often requires proof of diagnosis for conditions like plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis.

**Documentation:** Submission of prior authorization is necessary, detailing medical necessity based on Tufts' guidelines.

**Treatment History:** Evidence of prior unsuccessful treatments with alternative therapies may be required.

**Provider Requirements:** Coverage may stipulate that prescriptions come from network providers and pharmacies.

**Renewal:** Periodic re-evaluation of medical necessity is required for continued coverage.

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Tufts Health Plan's Approved Criteria for Cosentyx Coverage

Criteria for Initial Coverage of Cosentyx

**Diagnosis Verification**: The patient must have a confirmed diagnosis of one of the following conditions: plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis.

**Age Requirement**: The patient should be at least 18 years old.

**Previous Treatment**: The patient must have tried and failed, or is contraindicated for, at least two prior conventional therapies such as methotrexate, phototherapy, or corticosteroids.

**Disease Severity**: The severity of the condition must justify the use of Cosentyx, often defined as moderate to severe for plaque psoriasis or active psoriatic arthritis.

**Documentation**: Proper medical documentation must be provided, including prior treatment history and response, and current disease activity.

Criteria for Renewal of Cosentyx Coverage

**Demonstrated Clinical Benefit**: The patient must show evidence of continued clinical benefit from Cosentyx therapy, which can include reduction in the severity of symptoms or improvement in quality of life.

**Compliance with Treatment**: There must be documentation confirming that the patient is compliant with prescribed dosing and treatment schedule.

**Absence of Adverse Effects**: There should be no severe adverse reactions to the medication that would make continuation inappropriate.

**Regular Monitoring**: The patient should have regular follow-up appointments to monitor effectiveness and safety of treatment.

Why Tufts Health Plan Might Deny Cosentyx Coverage

Situations When Tufts Health Plan Might Deny Cosentyx Coverage

**Non-FDA Approved Indications**: Coverage is denied if Cosentyx is prescribed for conditions not approved by the FDA.

**Lack of Medical Necessity**: If it is determined that Cosentyx is not medically necessary for the patient's condition, coverage may be denied.

**Failure to Meet Prior Authorization Requirements**: If the necessary prior authorization has not been obtained before starting treatment, coverage could be denied.

**No Previous Treatments Attempts**: If there is no evidence of trying and failing other preferred treatments, Tufts Health Plan might deny coverage for Cosentyx.

**Duplicate Therapy**: When Cosentyx is prescribed along with another similar medication, coverage may be denied to prevent duplicate therapies.

**Non-Compliance With Plan Guidelines**: Failure to meet the clinical guidelines or protocols specified by Tufts Health Plan for Cosentyx can result in denial.

**Experimental or Investigational Use**: If Cosentyx is used in a manner considered experimental or investigational, it may not be covered.

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How Much Does Cosentyx Cost without Insurance?

Cost of Cosentyx Without Insurance

The cost of Cosentyx without insurance can vary depending on the pharmacy and location. However, the average retail price is typically around $5,500 to $6,000 per 150 mg dose.

Patients often need multiple doses, so the total cost can increase significantly depending on treatment duration and dosing requirements prescribed by a healthcare provider.

The pricing may also differ if there are discounts, special pharmacy funding programs, or if a patient qualifies for any manufacturer-sponsored assistance programs.

Generic versions are not available, as Cosentyx is a brand-name biologic medication.

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 Cosentyx Coverage with Tufts Health Plan

Check Your Plan Benefits

Access your Tufts Health Plan member portal online to review your specific benefits.
Look for prescription drug coverage details to see if Cosentyx is listed or inquire about specialty medications.
Contact Tufts Health Plan customer service for clarification on your current plan's coverage for Cosentyx.

Consult Your Healthcare Provider

Discuss your treatment options with your healthcare provider and express interest in starting Cosentyx.
Ask your healthcare provider if they are aware of Tufts Health Plan requirements for Cosentyx coverage.
Obtain a prescription for Cosentyx if your healthcare provider agrees it's appropriate for your treatment.

Submit a Prior Authorization Request

Your healthcare provider should submit a prior authorization request to Tufts Health Plan on your behalf.
Ensure the request includes all necessary documentation, such as medical necessity and any past treatments you've tried.
Follow up with your healthcare provider to verify that the request has been submitted and received by Tufts Health Plan.

Contact Specialty Pharmacy

If you have been approved, Tufts Health Plan will likely direct you to a specialty pharmacy to receive Cosentyx.
Coordinate with the specialty pharmacy to arrange shipment of your medication as per your prescription schedule.
Ask about any potential co-pay assistance or programs for which you may be eligible through the pharmacy or Cosentyx manufacturer.

Appeal if Necessary

If your initial request for Cosentyx coverage is denied, review the denial letter for specific reasons provided by Tufts Health Plan.
Work with your healthcare provider to gather additional supporting documentation or to adjust the prior authorization request.
Submit an appeal following the instructions provided in the denial letter and keep in touch with Tufts Health Plan for updates.

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Cosentyx FAQ

1. What are the side effects of Cosentyx?

Potential Side Effects of Cosentyx

Common Side Effects: These include upper respiratory tract infections, headache, and diarrhea. Users might also experience cold-like symptoms.

Serious Side Effects: Serious infections can occur due to immune suppression. Patients should monitor for signs of infections, such as persistent fever or cough.

Allergic Reactions: Watch for signs like difficulty breathing, swelling, or rash; these may indicate a severe allergic reaction.

Laboratory Abnormalities: Changes in white blood cell counts and liver enzymes may surface, necessitating monitoring.

2. How does Cosentyx work for psoriasis?

How Cosentyx Works

Cosentyx is a biologic medication specifically targeting the immune system by inhibiting interleukin-17A (IL-17A), a protein that plays a key role in inflammation.

By blocking IL-17A, Cosentyx reduces inflammation, thus decreasing the symptoms and plaques associated with psoriasis.

It helps control the abnormal skin cell growth and can lead to significant skin clearance in many patients.

Usage and Administration

Cosentyx is administered via subcutaneous injection, typically beginning with a loading dose followed by a maintenance dose.

It is crucial for the success of the treatment to follow the prescribed dosing schedule closely.

Potential Side Effects

Common side effects include respiratory infections, headache, and injection site reactions.

Patients should consult their healthcare provider for any severe or unusual symptoms.

3. Is Cosentyx a biologic medication?

Is Cosentyx a Biologic Medication?

Yes, Cosentyx is a biologic medication. It is a human monoclonal antibody that selectively binds to the interleukin-17A (IL-17A) cytokine, which plays a major role in inflammatory conditions.

Biologics are typically derived from living cells and are used in the treatment of various autoimmune diseases. Cosentyx is specifically used for conditions such as plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis.

Unlike traditional small-molecule drugs, biologics like Cosentyx target specific components of the immune system.

Cosentyx is administered through subcutaneous injections, typically prescribed after other treatments have not provided adequate symptom control.

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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 Tufts Health Plan Cover Cosentyx

Find out if Tufts Health Plan covers Cosentyx, potential coverage obstacles, tips to secure coverage, cost without insurance, and answers to common questions.

Achieve Your Goals Faster with Curex