Does UPMC Health Plan Cover Enbrel

Discover UPMC's policies on Enbrel coverage, denial reasons, obtaining coverage, pricing without insurance, and FAQs in this comprehensive guide.
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“Curex is changing the landscape of allergies in 2024”
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UPMC Health Plan Coverage for Enbrel

 

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

  • Prior authorization is usually required to confirm medical necessity. Ensure documentation from a healthcare provider outlines the necessity and inefficacy of alternative treatments.
  •  

  • Coverage may depend on formulary status, requiring patients to try preferred medications before approval for Enbrel.
  •  

  • Members should consult their specific plan details or customer service for coverage specifics, as policies can differ based on the type of plan.

 

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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 Enbrel Coverage with UPMC Health Plan

 

Verify Enbrel Coverage

 

  • Contact UPMC Health Plan’s customer service to confirm whether Enbrel is included in your health plan's formulary. Have your plan ID ready for a more efficient service.
  •  

  • Check UPMC’s online member portal. Log in using your credentials and search for Enbrel under your medication benefits to verify coverage.

 

Consult with Healthcare Provider

 

  • Discuss your need for Enbrel with your healthcare provider. They can offer essential documentation or justification needed for getting the drug covered.
  •  

  • Ask your healthcare provider to submit a prior authorization request if Enbrel requires prior approval from UPMC Health Plan.

 

Submit Prior Authorization

 

  • Fill out the necessary forms for a prior authorization request. These can often be obtained from your healthcare provider or the UPMC Health Plan website.
  •  

  • Ensure all sections are completed accurately to avoid delays. Submit these forms via the methods provided by UPMC Health Plan (usually through fax or their online portal).

 

Appeal if Denied

 

  • If coverage is denied, read the denial letter to understand the reason. This will guide you in gathering additional information or documentation for an appeal.
  •  

  • File an appeal with UPMC Health Plan. Use the appeal process details provided in your denial letter or the UPMC Health Plan website. Include supporting documents from your healthcare provider.

 

Explore Patient Assistance Programs

 

  • Research and contact Enbrel's manufacturer for any assistance programs. They may offer financial help or temporary access programs while resolving coverage issues.
  •  

  • Consider nonprofit organizations that help patients afford medications; they might offer grants or financial support depending on your eligibility.

 

Consult a Pharmacist

 

  • Speak with your pharmacist about your Enbrel prescription. They may provide guidance on alternative options or consult with your healthcare provider for a suitable alternative.
  •  

  • Your pharmacist can also assist by providing your healthcare provider and UPMC Health Plan with additional information to support the prescribing of Enbrel.

 

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Does UPMC Health Plan Cover Enbrel

Discover UPMC's policies on Enbrel coverage, denial reasons, obtaining coverage, pricing without insurance, and FAQs in this comprehensive guide.
Curex allergy drops unboxing

Is Enbrel Covered by UPMC Health Plan

 

UPMC Health Plan Coverage for Enbrel

 

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

  • Prior authorization is usually required to confirm medical necessity. Ensure documentation from a healthcare provider outlines the necessity and inefficacy of alternative treatments.
  •  

  • Coverage may depend on formulary status, requiring patients to try preferred medications before approval for Enbrel.
  •  

  • Members should consult their specific plan details or customer service for coverage specifics, as policies can differ based on the type of plan.

 

A weight management program tailored to you

Start with Curex

UPMC Health Plan's Approved Criteria for Enbrel Coverage

 

UPMC Health Plan Criteria for Enbrel Coverage

 

  • **Diagnosis Requirement**:
    • Member must have a definitive diagnosis of Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, or Plaque Psoriasis confirmed by a rheumatologist or dermatologist.
  •  

  • **Previous Treatments**:
    • There should be documented evidence of inadequate clinical response, contraindication, or intolerance to methotrexate or other Disease-Modifying Anti-Rheumatic Drugs (DMARDs), unless contraindicated.
  •  

  • **Age Requirements**:
    • For Juvenile Idiopathic Arthritis, the member must be 2 years of age or older.
    • For other conditions, the member should be 18 years of age or older.
  •  

  • **Specialist Involvement**:
    • Prescription must be recommended or confirmed by a specialist in rheumatology, dermatology, or a related field appropriate to the diagnosis being treated.
  •  

  • **Dosage and Administration**:
    • The prescribed dose should align with FDA-approved labeling for the specific condition being treated.
  •  

  • **Monitoring and Assessment**:
    • There must be a documented plan for monitoring the clinical response to treatment and potential side effects.
    • Regular follow-up assessments must be scheduled to evaluate effectiveness and safety of the treatment.
  •  

  • **Insurance Status**:
    • The member should be actively enrolled in the UPMC Health Plan and must have pharmacy benefits that include prescription drugs.
  •  

  • **Prior Authorization**:
    • Enrollment in the health plan's prior authorization program for biologic DMARD therapy is necessary to access coverage benefits for Enbrel.

 

Why UPMC Health Plan Might Deny Enbrel Coverage

 

When Treatment Criteria are Not Met

 

  • Enbrel may be denied if the clinical guidelines and criteria for its use are not met. These criteria often include the severity of the condition or the failure of other first-line treatments.

 

Non-FDA Approved Uses

 

  • Coverage for Enbrel may be denied if prescribed for conditions not approved by the Food and Drug Administration (FDA) for this medication.

 

Lack of Medical Necessity

 

  • Denial may occur if Enbrel is not deemed medically necessary according to the plan’s internal policies or medical guidelines.

 

Incomplete Documentation

 

  • Claims may be rejected due to insufficient or incomplete documentation from the healthcare provider, including a lack of prior authorization as required.

 

Non-Compliance with Prior Authorization

 

  • If prior authorization is required and not obtained, UPMC Health Plan may deny coverage for Enbrel.

 

Exceeding Quantity Limits

 

  • Coverage may be denied if the prescribed dosage exceeds the UPMC Health Plan's quantity limits for Enbrel.

 

Non-Covered Population

 

  • Use of Enbrel may be denied for populations outside approved age groups or other demographic restrictions specified by the plan.

 

Policy Exclusions

 

  • Denial might occur if Enbrel use falls under specific policy exclusions within the member’s plan, which could include certain types of care or treatment.

 

Together with our partners we have changed the lives of over 300,000 patients.

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 UPMC Health Plan

 

Verify Enbrel Coverage

 

  • Contact UPMC Health Plan’s customer service to confirm whether Enbrel is included in your health plan's formulary. Have your plan ID ready for a more efficient service.
  •  

  • Check UPMC’s online member portal. Log in using your credentials and search for Enbrel under your medication benefits to verify coverage.

 

Consult with Healthcare Provider

 

  • Discuss your need for Enbrel with your healthcare provider. They can offer essential documentation or justification needed for getting the drug covered.
  •  

  • Ask your healthcare provider to submit a prior authorization request if Enbrel requires prior approval from UPMC Health Plan.

 

Submit Prior Authorization

 

  • Fill out the necessary forms for a prior authorization request. These can often be obtained from your healthcare provider or the UPMC Health Plan website.
  •  

  • Ensure all sections are completed accurately to avoid delays. Submit these forms via the methods provided by UPMC Health Plan (usually through fax or their online portal).

 

Appeal if Denied

 

  • If coverage is denied, read the denial letter to understand the reason. This will guide you in gathering additional information or documentation for an appeal.
  •  

  • File an appeal with UPMC Health Plan. Use the appeal process details provided in your denial letter or the UPMC Health Plan website. Include supporting documents from your healthcare provider.

 

Explore Patient Assistance Programs

 

  • Research and contact Enbrel's manufacturer for any assistance programs. They may offer financial help or temporary access programs while resolving coverage issues.
  •  

  • Consider nonprofit organizations that help patients afford medications; they might offer grants or financial support depending on your eligibility.

 

Consult a Pharmacist

 

  • Speak with your pharmacist about your Enbrel prescription. They may provide guidance on alternative options or consult with your healthcare provider for a suitable alternative.
  •  

  • Your pharmacist can also assist by providing your healthcare provider and UPMC Health Plan with additional information to support the prescribing of Enbrel.

 

Premium Medication you can trust

Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

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.

 

Have questions left?

Get a personalized online consultation with a doctor at Curex

Curex is one of America’s largest telehealth providers

Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
journey now

Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

A weight management program tailored to you

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 Enbrel

Discover UPMC's policies on Enbrel coverage, denial reasons, obtaining coverage, pricing without insurance, and FAQs in this comprehensive guide.
Curex allergy drops unboxing

Does UPMC Health Plan Cover Enbrel

 

UPMC Health Plan Coverage for Enbrel

 

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

  • Prior authorization is usually required to confirm medical necessity. Ensure documentation from a healthcare provider outlines the necessity and inefficacy of alternative treatments.
  •  

  • Coverage may depend on formulary status, requiring patients to try preferred medications before approval for Enbrel.
  •  

  • Members should consult their specific plan details or customer service for coverage specifics, as policies can differ based on the type of plan.

 

A weight management program tailored to you

Start with Curex

Why UPMC Health Plan Might Deny Enbrel Coverage

 

UPMC Health Plan Criteria for Enbrel Coverage

 

  • **Diagnosis Requirement**:
    • Member must have a definitive diagnosis of Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, Juvenile Idiopathic Arthritis, or Plaque Psoriasis confirmed by a rheumatologist or dermatologist.
  •  

  • **Previous Treatments**:
    • There should be documented evidence of inadequate clinical response, contraindication, or intolerance to methotrexate or other Disease-Modifying Anti-Rheumatic Drugs (DMARDs), unless contraindicated.
  •  

  • **Age Requirements**:
    • For Juvenile Idiopathic Arthritis, the member must be 2 years of age or older.
    • For other conditions, the member should be 18 years of age or older.
  •  

  • **Specialist Involvement**:
    • Prescription must be recommended or confirmed by a specialist in rheumatology, dermatology, or a related field appropriate to the diagnosis being treated.
  •  

  • **Dosage and Administration**:
    • The prescribed dose should align with FDA-approved labeling for the specific condition being treated.
  •  

  • **Monitoring and Assessment**:
    • There must be a documented plan for monitoring the clinical response to treatment and potential side effects.
    • Regular follow-up assessments must be scheduled to evaluate effectiveness and safety of the treatment.
  •  

  • **Insurance Status**:
    • The member should be actively enrolled in the UPMC Health Plan and must have pharmacy benefits that include prescription drugs.
  •  

  • **Prior Authorization**:
    • Enrollment in the health plan's prior authorization program for biologic DMARD therapy is necessary to access coverage benefits for Enbrel.

 

Together with our partners we have changed the lives of over 300,000 patients.

Enbrel FAQ

 

When Treatment Criteria are Not Met

 

  • Enbrel may be denied if the clinical guidelines and criteria for its use are not met. These criteria often include the severity of the condition or the failure of other first-line treatments.

 

Non-FDA Approved Uses

 

  • Coverage for Enbrel may be denied if prescribed for conditions not approved by the Food and Drug Administration (FDA) for this medication.

 

Lack of Medical Necessity

 

  • Denial may occur if Enbrel is not deemed medically necessary according to the plan’s internal policies or medical guidelines.

 

Incomplete Documentation

 

  • Claims may be rejected due to insufficient or incomplete documentation from the healthcare provider, including a lack of prior authorization as required.

 

Non-Compliance with Prior Authorization

 

  • If prior authorization is required and not obtained, UPMC Health Plan may deny coverage for Enbrel.

 

Exceeding Quantity Limits

 

  • Coverage may be denied if the prescribed dosage exceeds the UPMC Health Plan's quantity limits for Enbrel.

 

Non-Covered Population

 

  • Use of Enbrel may be denied for populations outside approved age groups or other demographic restrictions specified by the plan.

 

Policy Exclusions

 

  • Denial might occur if Enbrel use falls under specific policy exclusions within the member’s plan, which could include certain types of care or treatment.

 

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 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.

 

Premium Medication you can trust

Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

Curex is one of America’s largest telehealth providers

Together with our partners we have changed the lives of over 300,000 patients. Here’s what some of them have to say:

“Curex has performed beyond my expectations. I am feeling tremendously better and look forward to continuing the treatment.”
Becky D.
"If I could give 6 stars, I would. BEST... BEST… BEST… service.”
Ferdian K.
“The Curex staff has been professional, efficient, and really focused on my individual needs.”
Ana C.

Start your
journey now

Everything you need is included:

Online consultation

Your prescription

Premium medication

Overnight shipping

Ongoing support

A weight management program tailored to you

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.