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Does UPMC Health Plan Cover Dupixent

Explore Dupixent coverage with UPMC Health Plan, reasons for denial, steps for approval, costs without insurance, and FAQs in this informative article.

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UPMC Health Plan Coverage for Dupixent

UPMC Health Plan may cover Dupixent (dupilumab) for conditions like moderate-to-severe atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis, subject to prior authorization.

Coverage depends on the patient's specific policy details and medical necessity as determined by a healthcare provider.

Criteria for coverage often include documented medical history, previous treatments attempted, and lab results demonstrating the need for Dupixent.

Members are usually required to try other lower-cost medications before Dupixent is approved unless contraindicated.

It's crucial to consult UPMC's specific formulary or a plan representative for detailed coverage information and authorization process.

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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.

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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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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 Dupixent Coverage with UPMC Health Plan

Initiate Contact with UPMC Health Plan

Start by contacting UPMC Health Plan's customer service. You can usually find the phone number on your insurance card or the health plan's official website.

Request to speak with a representative who can provide details on Dupixent coverage and what the requirements are for authorization.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss Dupixent treatment.

Ask your healthcare provider to prepare all necessary documentation to prove the medical necessity for Dupixent. This may include medical records, history of treatments, and detailed explanations of your condition.

Submit Required Documentation

Work with your healthcare provider to submit the completed documentation to UPMC Health Plan. Ensure that all forms are filled out accurately and all requested information is provided.

Ask your healthcare provider to include a letter of medical necessity and any supporting documents that reinforce the need for Dupixent.

Follow Up with UPMC Health Plan

After submitting documentation, follow up with UPMC Health Plan to confirm that they have received all necessary information.

Inquire about the timeline for the review process and any additional steps you may need to take during this time.

Appeal if Necessary

If your request for Dupixent coverage is denied, review the denial letter to understand the reasons cited.

Determine the appeal process and discuss with your healthcare provider how best to address the reasons for denial.

Prepare and submit an appeal along with any additional documentation or clarifications needed to support your case.

Verify Coverage Approval

Once approved, verify the details of your Dupixent coverage, including any copays, deductibles, or specific conditions that apply.

Coordinate with your pharmacy to ensure timely and correctly processed prescriptions.

Maintain Open Communication

Continue communicating with both UPMC Health Plan and your healthcare provider regarding your treatment and any changes or updates needed in your coverage.

Keep records of all communications, approvals, and appointments related to your Dupixent treatment and insurance coverage.

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Does UPMC Health Plan Cover Dupixent

Explore Dupixent coverage with UPMC Health Plan, reasons for denial, steps for approval, costs without insurance, and FAQs in this informative article.

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Is Dupixent Covered by UPMC Health Plan

UPMC Health Plan Coverage for Dupixent

UPMC Health Plan may cover Dupixent (dupilumab) for conditions like moderate-to-severe atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis, subject to prior authorization.

Coverage depends on the patient's specific policy details and medical necessity as determined by a healthcare provider.

Criteria for coverage often include documented medical history, previous treatments attempted, and lab results demonstrating the need for Dupixent.

Members are usually required to try other lower-cost medications before Dupixent is approved unless contraindicated.

It's crucial to consult UPMC's specific formulary or a plan representative for detailed coverage information and authorization process.

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UPMC Health Plan's Approved Criteria for Dupixent Coverage

Eligibility for Dupixent Coverage

The patient must have a confirmed diagnosis by a healthcare provider of one of the following conditions: moderate to severe atopic dermatitis, asthma, or chronic rhinosinusitis with nasal polyposis.

For atopic dermatitis, the patient is required to have an inadequate response or intolerance to topical prescription therapies, or have a condition that cannot be controlled with topical treatments alone.

For asthma, the patient must be at least 12 years old with a diagnosis of moderate to severe asthma and demonstrate documented evidence of inadequately controlled asthma despite the use of medium-to-high-dose inhaled corticosteroids plus another asthma controller medication.

In the case of chronic rhinosinusitis with nasal polyposis, the patient must show an inadequate response or intolerance to other available therapies.

Medical Necessity

The prescribing physician must confirm Dupixent is medically necessary for the patient's condition based on current clinical guideline recommendations.

Documentation from the physician must show that Dupixent is an appropriate treatment option based on the individual's unique clinical status and treatment history.

Evidence must exist that the patient has tried and failed other treatments, such as systemic therapies or biologics, to qualify for Dupixent under medical necessity circumstances.

Patient History and Previous Treatments

A detailed medical history indicating previous treatments that were tried and their results must be submitted, showing a clear need for Dupixent therapy.

The patient's history should include previous medications, dosages, and the duration of past treatments, alongside any adverse reactions or insufficient responses.

Failure of first and second-line therapies must be clearly documented in the patient's medical records, and specific reasons for treatment discontinuation should be noted.

Additional Criteria for Children

Dupixent coverage for children aged 6-11 years with moderate-to-severe atopic dermatitis requires documented assessment and diagnosis confirmation by a pediatric dermatologist or allergist.

The child must have had an inadequate response to topical prescription therapies, as well as a medical necessity statement specifying why Dupixent is considered appropriate and necessary.

Renewal Criteria

Continued coverage of Dupixent requires documentation of a positive clinical response since starting the medication, which may include a reduction in symptom severity or improvement in quality of life metrics.

The prescribing physician must provide a follow-up assessment indicating sustained benefit and the necessity of ongoing treatment with Dupixent.

Lack of adherence to treatment regimens or unjustified duplication of therapies would require review before approval for renewal of coverage.

Why UPMC Health Plan Might Deny Dupixent Coverage

Situations When UPMC Health Plan Might Deny Dupixent Coverage

Dupixent is not prescribed for an FDA-approved indication. Coverage is typically denied if the medication is being used for an off-label condition that lacks sufficient evidence of effectiveness.

The patient does not meet the specific clinical criteria set by the UPMC Health Plan. These criteria might include requirements such as failure to respond to other treatments, severity of the condition, or specific diagnostic testing.

Lack of necessary documentation from the healthcare provider, including detailed medical records and a thorough rationale for prescribing Dupixent, can lead to a denial of coverage.

The request for Dupixent exceeds plan limits, such as exceeding the recommended dosage or frequency without prior authorization, may result in denial unless adequately justified by the healthcare provider.

If the patient fails to comply with prerequisite alternative therapy treatments as determined by UPMC Health Plan. For instance, they might necessitate trials with lower-cost treatments before approving Dupixent.

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How Much Does Dupixent Cost without Insurance?

Approximate Cost of Dupixent Without Insurance

The cost of Dupixent without insurance can be quite high, usually ranging between $3,200 to $3,500 per month. This cost is for the standard dose, which consists of two pre-filled syringes or injection pens, each containing 300 mg of medication.

Prices can vary depending on the pharmacy, location, and any potential deals or discounts offered by specific pharmacies or third-party services.

Patients are encouraged to explore manufacturer copay cards, patient assistance programs, or discount cards which might be available to help reduce out-of-pocket expenses.

For those requiring treatment for conditions like eczema, asthma, or other approved uses, Dupixent is often administered bi-weekly after an initial loading dose, which should be taken into consideration when calculating monthly or annual expenses.

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 Dupixent Coverage with UPMC Health Plan

Initiate Contact with UPMC Health Plan

Start by contacting UPMC Health Plan's customer service. You can usually find the phone number on your insurance card or the health plan's official website.

Request to speak with a representative who can provide details on Dupixent coverage and what the requirements are for authorization.

Consult with Your Healthcare Provider

Schedule an appointment with your healthcare provider to discuss Dupixent treatment.

Ask your healthcare provider to prepare all necessary documentation to prove the medical necessity for Dupixent. This may include medical records, history of treatments, and detailed explanations of your condition.

Submit Required Documentation

Work with your healthcare provider to submit the completed documentation to UPMC Health Plan. Ensure that all forms are filled out accurately and all requested information is provided.

Ask your healthcare provider to include a letter of medical necessity and any supporting documents that reinforce the need for Dupixent.

Follow Up with UPMC Health Plan

After submitting documentation, follow up with UPMC Health Plan to confirm that they have received all necessary information.

Inquire about the timeline for the review process and any additional steps you may need to take during this time.

Appeal if Necessary

If your request for Dupixent coverage is denied, review the denial letter to understand the reasons cited.

Determine the appeal process and discuss with your healthcare provider how best to address the reasons for denial.

Prepare and submit an appeal along with any additional documentation or clarifications needed to support your case.

Verify Coverage Approval

Once approved, verify the details of your Dupixent coverage, including any copays, deductibles, or specific conditions that apply.

Coordinate with your pharmacy to ensure timely and correctly processed prescriptions.

Maintain Open Communication

Continue communicating with both UPMC Health Plan and your healthcare provider regarding your treatment and any changes or updates needed in your coverage.

Keep records of all communications, approvals, and appointments related to your Dupixent treatment and insurance coverage.

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Dupixent FAQ

1. What are the common side effects of Dupixent?

Common Side Effects of Dupixent

Injection site reactions: redness, swelling, and pain at the injection site are frequently reported. These reactions usually subside shortly after injection.

Conjunctivitis: Some patients experience symptoms like red, itchy, or watery eyes.

Blepharitis: Inflammation of the eyelids, leading to symptoms such as redness, swelling, and itching, may occur.

Oral herpes: A mild increase in probabilities of cold sores has been noted in some cases.

Sore throat: Some individuals may develop pharyngitis, which manifests as throat discomfort or pain.

2. How does Dupixent work for eczema?

How Dupixent Works for Eczema

Dupixent is a monoclonal antibody that targets interleukin-4 receptor alpha (IL-4Rα).

By blocking IL-4Rα, it inhibits the signaling pathways of IL-4 and IL-13, key cytokines involved in the inflammatory response in eczema.

This leads to a reduction in the overactive immune response, which is characterized by inflammation and itchiness in atopic dermatitis.

As a result, Dupixent helps alleviate symptoms like redness, itch, and skin thickening by modulating the immune response.

3. Is Dupixent used for asthma treatment?

Dupixent for Asthma

Dupixent (dupilumab) is approved for use in the treatment of moderate-to-severe asthma in adults and adolescents (12 years and older).

It is particularly beneficial for patients with eosinophilic asthma or those dependent on oral corticosteroids.

Dupixent acts by targeting and inhibiting the signaling of interleukins IL-4 and IL-13, which play central roles in the inflammatory response involved in asthma.

The medication is administered via subcutaneous injection, typically every two weeks after an initial loading dose.

Clinical trials have shown Dupixent to reduce asthma exacerbations and improve lung function, thereby potentially reducing the need for oral corticosteroids.

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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 UPMC Health Plan Cover Dupixent

Explore Dupixent coverage with UPMC Health Plan, reasons for denial, steps for approval, costs without insurance, and FAQs in this informative article.

Achieve Your Goals Faster with Curex