Does Tufts Health Plan Cover Enbrel

Learn about Enbrel coverage by Tufts Health Plan. Explore coverage denial, getting coverage, cost without insurance, and answers to common Enbrel questions.
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Enbrel Coverage by Tufts Health Plan

 

  • Tufts Health Plan typically covers Enbrel for conditions like rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.
  •  

  • Coverage requires prior authorization, where your healthcare provider must demonstrate medical necessity.
  •  

  • Criteria for Enbrel coverage may include insufficient response to traditional therapies and confirmation of diagnosis.
  •  

  • Patients might need to enroll in a specialty pharmacy program as part of the coverage process.
  •  

  • Be sure to check your specific plan's benefits, as coverage may vary between plans and networks.

 

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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 Tufts Health Plan

 

Initial Steps in Understanding Your Coverage

 

  • Review your Tufts Health Plan documentation to understand the specifics of your current prescription drug coverage. Be aware of formulary details, any applicable tiers, and any prior authorization requirements.
  •  

  • Contact Tufts Health Plan customer service by using the number on your insurance card to verify if Enbrel is covered under your specific plan.

 

Consult with Your Healthcare Provider

 

  • Discuss your need for Enbrel with your healthcare provider to get a strong understanding of why it is the best treatment option for your condition.
  •  

  • Your healthcare provider should be ready to provide necessary medical documentation that supports your need for Enbrel, such as treatment history and a rationale for choosing this medication.

 

Initiate the Prior Authorization Process

 

  • If Enbrel requires prior authorization, ensure your healthcare provider submits a prior authorization request form to Tufts Health Plan. This typically includes patient history, diagnosis, and justification for the medication.
  •  

  • Work closely with your provider to gather any additional required documentation and ensure it is submitted along with the prior authorization request.

 

Follow-Up and Await Approval

 

  • Monitor the status of your prior authorization request by keeping in contact with both your healthcare provider and Tufts Health Plan. This helps address any additional requests or questions promptly.
  •  

  • Once approved, review any conditions or coverage limits outlined in your approval notice so you understand the scope of coverage for Enbrel.

 

Exploring Financial Assistance Programs

 

  • If there are still significant out-of-pocket costs following insurance coverage, explore financial assistance options. Programs such as Enbrel Support or co-pay assistance offers might be available to help reduce costs.
  •  

  • Contact the Enbrel Support program to assess eligibility for co-pay assistance, discounts, or payment plans.

 

Finalizing the Process

 

  • Upon receiving approval, coordinate with your pharmacy to fill your Enbrel prescription as per the coverage details provided by Tufts Health Plan.
  •  

  • Keep records of all communications and approvals for future reference or in case of any disputes concerning your coverage.

 

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FAQs

Does Tufts Health Plan Cover Enbrel

Learn about Enbrel coverage by Tufts Health Plan. Explore coverage denial, getting coverage, cost without insurance, and answers to common Enbrel questions.
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Is Enbrel Covered by Tufts Health Plan

 

Enbrel Coverage by Tufts Health Plan

 

  • Tufts Health Plan typically covers Enbrel for conditions like rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.
  •  

  • Coverage requires prior authorization, where your healthcare provider must demonstrate medical necessity.
  •  

  • Criteria for Enbrel coverage may include insufficient response to traditional therapies and confirmation of diagnosis.
  •  

  • Patients might need to enroll in a specialty pharmacy program as part of the coverage process.
  •  

  • Be sure to check your specific plan's benefits, as coverage may vary between plans and networks.

 

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Tufts Health Plan's Approved Criteria for Enbrel Coverage

 

Eligibility Criteria for Enbrel Coverage

 

  • Enbrel is covered for the treatment of rheumatoid arthritis in adult patients who have had an inadequate response to traditional disease-modifying antirheumatic drugs (DMARDs).
  •  

  • For juvenile idiopathic arthritis, Enbrel is covered for patients aged 2 and older with moderate to severe active disease.
  •  

  • Coverage for Enbrel is available for patients with active ankylosing spondylitis who have tried and had an inadequate response to at least two nonsteroidal anti-inflammatory drugs (NSAIDs).
  •  

  • Enbrel is approved for patients with psoriatic arthritis when they have minimal response to at least two different DMARDs.
  •  

  • For chronic moderate to severe plaque psoriasis, Enbrel is covered for adult patients who are candidates for systemic therapy or phototherapy and have failed to respond to, or have contraindications to, other systemic therapies.

 

Dosage and Administration

 

  • Patients must adhere to the specific dosage and administration guidelines as recommended by their healthcare provider and as listed in the FDA-approved prescribing information.
  •  

  • The prescribed dosage regimen must align with guidelines for the specific condition being treated.

 

Specialty Pharmacy Requirement

 

  • Enbrel must be obtained through a Tufts Health Plan-designated specialty pharmacy for coverage to apply.

 

Prescription Documentation

 

  • Detailed documentation from the prescribing healthcare provider must be provided, including the patient's diagnosis, treatment history, and response to previous therapies.
  •  

  • Continuation of therapy will require periodic clinical review to ensure that the patient benefits from the treatment.

 

Economic Considerations

 

  • Patients may be required to try and fail lower-cost formulation alternatives before Enbrel is approved for coverage.
  •  

  • Tufts Health Plan may require a co-pay or co-insurance, depending on the member's specific insurance plan.

 

Why Tufts Health Plan Might Deny Enbrel Coverage

 

Situations When Enbrel Coverage Might Be Denied by Tufts Health Plan

 

  • The use of Enbrel does not meet the specific medical necessity criteria as determined by Tufts Health Plan. This includes cases where alternative treatments are available and recommended for the patient's condition.
  •  

  • Lack of proper documentation or failure to provide necessary clinical information supporting the need for Enbrel. This could involve incomplete evidence of attempted use of other standard therapies.
  •  

  • Using Enbrel for non-FDA approved indications is not covered unless there is substantial evidence supporting such use in the medical literature as per their policy guidelines.
  •  

  • The patient does not meet the age or diagnostic criteria specified by Tufts Health Plan's policy for Enbrel coverage. This may include situations where the patient's demographic details do not match covered conditions.
  •  

  • Failure to respond to a previous course of therapy with Enbrel under Tufts Health Plan’s documented success criteria might result in denial of subsequent coverage.
  •  

  • Prescription of Enbrel exceeding the maximum allowed dosage or duration as specified by Tufts Health Plan’s guidelines is likely to not be covered.
  •  

  • Prescriptions from practitioners not recognized or not registered with Tufts Health Plan might lead to Enbrel coverage being denied.

 

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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 Tufts Health Plan

 

Initial Steps in Understanding Your Coverage

 

  • Review your Tufts Health Plan documentation to understand the specifics of your current prescription drug coverage. Be aware of formulary details, any applicable tiers, and any prior authorization requirements.
  •  

  • Contact Tufts Health Plan customer service by using the number on your insurance card to verify if Enbrel is covered under your specific plan.

 

Consult with Your Healthcare Provider

 

  • Discuss your need for Enbrel with your healthcare provider to get a strong understanding of why it is the best treatment option for your condition.
  •  

  • Your healthcare provider should be ready to provide necessary medical documentation that supports your need for Enbrel, such as treatment history and a rationale for choosing this medication.

 

Initiate the Prior Authorization Process

 

  • If Enbrel requires prior authorization, ensure your healthcare provider submits a prior authorization request form to Tufts Health Plan. This typically includes patient history, diagnosis, and justification for the medication.
  •  

  • Work closely with your provider to gather any additional required documentation and ensure it is submitted along with the prior authorization request.

 

Follow-Up and Await Approval

 

  • Monitor the status of your prior authorization request by keeping in contact with both your healthcare provider and Tufts Health Plan. This helps address any additional requests or questions promptly.
  •  

  • Once approved, review any conditions or coverage limits outlined in your approval notice so you understand the scope of coverage for Enbrel.

 

Exploring Financial Assistance Programs

 

  • If there are still significant out-of-pocket costs following insurance coverage, explore financial assistance options. Programs such as Enbrel Support or co-pay assistance offers might be available to help reduce costs.
  •  

  • Contact the Enbrel Support program to assess eligibility for co-pay assistance, discounts, or payment plans.

 

Finalizing the Process

 

  • Upon receiving approval, coordinate with your pharmacy to fill your Enbrel prescription as per the coverage details provided by Tufts Health Plan.
  •  

  • Keep records of all communications and approvals for future reference or in case of any disputes concerning your coverage.

 

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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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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 (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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