Will health insurance cover Enbrel?
Are you wondering if your health insurance will cover Enbrel? Read this informative article to find out if this medication is covered by your insurance plan and what you need to know about potential costs and coverage.
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Dani Best has been a licensed insurance producer for nearly 10 years. Dani began her insurance career in a sales role with State Farm in 2014. During her time in sales, she graduated with her Bachelors in Psychology from Capella University and is currently earning her Masters in Marriage and Family Therapy. Since 2014, Dani has held and maintains licenses in Life, Disability, Property, and Casualt...
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UPDATED: Dec 1, 2023
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UPDATED: Dec 1, 2023
It’s all about you. We want to help you make the right coverage choices.
Advertiser Disclosure: We strive to help you make confident insurance decisions. Comparison shopping should be easy. We are not affiliated with any one insurance company and cannot guarantee quotes from any single insurance company.
Our insurance industry partnerships don’t influence our content. Our opinions are our own. To compare quotes from many different insurance companies please enter your ZIP code above to use the free quote tool. The more quotes you compare, the more chances to save.
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Enbrel is a medication that is widely prescribed for the treatment of autoimmune conditions such as rheumatoid arthritis and psoriasis. If you are considering starting Enbrel as part of your treatment plan, one question that may be on your mind is whether your health insurance will cover the cost. In this article, we will explore the factors that determine whether health insurance covers Enbrel, as well as alternatives that may be available to you if your insurance does not provide coverage.
Understanding Enbrel: What is it and what does it treat?
Enbrel, also known by its generic name etanercept, is a medication that belongs to a class of drugs known as tumor necrosis factor (TNF) inhibitors. It works by blocking the activity of TNF, a protein in the body that is involved in inflammation. By inhibiting TNF, Enbrel helps to reduce inflammation and alleviate symptoms associated with autoimmune conditions.
Enbrel is typically prescribed for the treatment of rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, and juvenile idiopathic arthritis. It can help to relieve joint pain, reduce swelling and stiffness, and improve overall physical functioning and quality of life for individuals with these conditions.
The medical uses of Enbrel
Enbrel is approved by the U.S. Food and Drug Administration (FDA) for the treatment of several autoimmune conditions, including:
- Rheumatoid arthritis
- Psoriasis
- Psoriatic arthritis
- Ankylosing spondylitis
- Juvenile idiopathic arthritis
Enbrel has been a game-changer for individuals living with these conditions. Rheumatoid arthritis, for example, is a chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness. With Enbrel, patients experience significant relief from these debilitating symptoms, allowing them to lead more active and fulfilling lives.
Psoriasis, another condition that Enbrel is approved to treat, is a chronic skin disease characterized by red, itchy, and scaly patches. Enbrel helps to suppress the overactive immune response that triggers psoriasis, resulting in clearer skin and improved self-esteem for those affected.
Psoriatic arthritis, a form of arthritis that affects some individuals with psoriasis, can cause joint pain, stiffness, and swelling. Enbrel has been shown to effectively manage these symptoms, allowing patients to engage in daily activities without the limitations imposed by the disease.
Ankylosing spondylitis, a type of arthritis that primarily affects the spine and sacroiliac joints, can cause chronic pain and stiffness. Enbrel helps to reduce inflammation in these areas, providing relief and improving mobility for individuals with this condition.
Juvenile idiopathic arthritis, which affects children under the age of 16, can cause joint pain, swelling, and stiffness. Enbrel has proven to be a valuable treatment option for young patients, helping them to manage their symptoms and maintain an active lifestyle.
It is important to note that Enbrel is a prescription medication and should only be used under the guidance and supervision of a healthcare professional.
Side effects and risks of Enbrel
Like any medication, Enbrel may cause side effects in some individuals. Common side effects of Enbrel include injection site reactions, such as redness, pain, and swelling at the injection site. These reactions are usually mild and temporary.
Other potential side effects include headache, nausea, respiratory infections, and allergic reactions. While these side effects are less common, it is important to be aware of them and report any unusual symptoms to a healthcare provider.
It is also important to be aware of certain risks associated with Enbrel. TNF inhibitors like Enbrel may increase the risk of serious infections, including tuberculosis and fungal infections. These medications may also increase the risk of certain types of cancer, such as lymphoma.
However, it is crucial to understand that the benefits of Enbrel often outweigh the potential risks. Healthcare providers carefully evaluate each patient’s medical history and assess the potential risks before prescribing Enbrel. Regular monitoring and communication with a healthcare provider can help mitigate any potential risks and ensure the safe and effective use of Enbrel.
Individuals considering Enbrel should discuss the potential risks and benefits with their healthcare provider to make an informed decision. It is essential to have open and honest conversations about individual health conditions, treatment goals, and any concerns to ensure the best possible outcomes.
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The cost of Enbrel without insurance
Enbrel is a specialty medication that can be quite expensive, especially without insurance coverage. The cost of a monthly supply of Enbrel can range from several hundred to over a thousand dollars, depending on the dosage and quantity prescribed.
Factors influencing the price of Enbrel
There are several factors that contribute to the high cost of Enbrel. The first is the complex manufacturing process involved in producing biologic medications like Enbrel. These medications are made from living cells and require stringent quality control measures.
In addition, Enbrel is protected by patents, which give the manufacturer exclusive rights to produce and market the medication for a certain period of time. During this period, other companies cannot produce generic versions of Enbrel, which often leads to higher prices.
Ways to reduce the cost of Enbrel
If you are concerned about the cost of Enbrel without insurance, there are several strategies you can explore to help reduce the financial burden:
- Look for patient assistance programs: The manufacturer of Enbrel, as well as nonprofit organizations, may offer patient assistance programs that provide financial assistance or discounts for eligible individuals.
- Explore insurance options: If you do not have health insurance, consider exploring options such as Medicaid, the Health Insurance Marketplace, or employer-sponsored plans that may provide coverage for Enbrel.
- Compare prices: Prices for specialty medications like Enbrel can vary between pharmacies. Take the time to compare prices and inquire about any available discounts or savings programs at different pharmacies.
Health insurance policies and prescription drug coverage
One of the primary sources of coverage for prescription medications, including Enbrel, is health insurance. Most health insurance policies provide some level of coverage for prescription drugs, but the specific details can vary widely.
How health insurance covers prescription drugs
The coverage for prescription drugs under health insurance policies may depend on several factors, including the individual policy, the insurance provider, and the specific drug being prescribed. Some health insurance policies may cover the full cost of certain medications, while others may require the patient to pay a copayment, coinsurance, or meet a deductible before coverage kicks in.
The role of formularies in health insurance
Health insurance plans often have a list of covered medications known as a formulary. Formularies are created by insurance companies in collaboration with healthcare providers and may include both generic and brand-name medications. Typically, medications that are considered more cost-effective or have therapeutic alternatives will be preferred on the formulary.
While Enbrel is a well-known and commonly prescribed medication, it may not be included on all formularies. Insurers may have preferred alternatives for the treatment of autoimmune conditions that they cover at a lower cost or with less restrictive requirements.
Does health insurance cover Enbrel?
Whether or not your health insurance will cover the cost of Enbrel depends on several factors, including your specific insurance policy, the formulary it follows, and the medical necessity of the medication for your condition.
Factors that determine if your insurance will cover Enbrel
Some of the factors that insurance companies consider when determining coverage for Enbrel include the following:
- Diagnosis: Insurance companies may require evidence of a confirmed diagnosis of an autoimmune condition for which Enbrel is indicated.
- Prior authorization: Some insurance plans may require healthcare providers to obtain prior authorization before prescribing Enbrel.
- Step therapy: Step therapy may require individuals to try and fail alternative medications before Enbrel coverage is approved.
How to find out if your insurance covers Enbrel
If you are unsure whether your health insurance covers Enbrel or if you have specific coverage questions, it is best to contact your insurance provider directly. They will be able to provide you with the most accurate and up-to-date information regarding your coverage.
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Alternatives to Enbrel if your insurance doesn’t cover it
If your health insurance does not cover the cost of Enbrel or if the out-of-pocket expense is too high, there may be alternatives that you can discuss with your healthcare provider.
Other medications for the same conditions
There are other medications available that belong to the same class of drugs as Enbrel, such as adalimumab (Humira) and infliximab (Remicade). These medications work in a similar way to Enbrel and are approved for the same conditions.
Your healthcare provider can evaluate your specific situation and determine whether one of these alternative medications may be a suitable option for you.
Non-pharmaceutical treatment options
In addition to medication, there may be non-pharmaceutical treatment options available for your specific condition. These can include physical therapy, occupational therapy, lifestyle modifications, and complementary therapies such as acupuncture or massage.
Working closely with your healthcare provider, you can explore these alternative treatment options and develop a comprehensive treatment plan that best meets your needs.
In conclusion
In summary, whether health insurance will cover the cost of Enbrel depends on various factors, including your specific insurance policy, formulary, and medical necessity for the medication. It is essential to understand your insurance coverage and explore alternative options if Enbrel is not covered. Discussing your concerns and treatment goals with your healthcare provider can help you make informed decisions about your medication options and overall treatment plan.
Frequently Asked Questions
Will health insurance cover Enbrel?
Health insurance coverage for Enbrel varies depending on the insurance plan. It is recommended to review your specific insurance policy or contact your insurance provider to determine if Enbrel is covered.
What is Enbrel?
Enbrel is a prescription medication that belongs to a class of drugs called tumor necrosis factor (TNF) inhibitors. It is used to treat certain autoimmune diseases such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.
How does Enbrel work?
Enbrel works by blocking the action of TNF, a substance in the body that causes inflammation. By reducing TNF levels, Enbrel helps to alleviate symptoms and manage the underlying autoimmune conditions.
What are the potential side effects of Enbrel?
Common side effects of Enbrel may include injection site reactions, infections, headache, nausea, and cold symptoms. Serious side effects are rare but can include severe allergic reactions, liver problems, nervous system disorders, and increased risk of infections.
Are there any alternatives to Enbrel?
Yes, there are alternative medications available for the treatment of autoimmune diseases. Some common alternatives to Enbrel include Humira, Remicade, Simponi, and Cimzia. The choice of medication depends on various factors, including the specific condition and individual patient needs.
Can Enbrel be used for conditions other than those mentioned?
Enbrel is primarily approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis. While it may be used off-label for other conditions, it is important to consult with a healthcare professional to determine the appropriateness and potential risks of such use.
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Dani Best
Licensed Insurance Producer
Dani Best has been a licensed insurance producer for nearly 10 years. Dani began her insurance career in a sales role with State Farm in 2014. During her time in sales, she graduated with her Bachelors in Psychology from Capella University and is currently earning her Masters in Marriage and Family Therapy. Since 2014, Dani has held and maintains licenses in Life, Disability, Property, and Casualt...
Licensed Insurance Producer
Editorial Guidelines: We are a free online resource for anyone interested in learning more about insurance. Our goal is to be an objective, third-party resource for everything insurance related. We update our site regularly, and all content is reviewed by insurance experts.