Have you or a loved one received an Enbrel Health Insurance Denial? We Can Help.
Enbrel® (Etanercept) treats autoimmune illnesses by acting as a tumor necrosis factor (TNF) inhibitor. First approved by The Food and Drug Administration in 1998 to treat Rheumatoid Arthritis, the FDA has since approved Enbrel for four other health conditions. Enbrel is a biological drug sold by Amgen in the United States. By blocking TNF, it helps reduce inflammation. This article reviews Enbrel health insurance coverage claims. It also looks at how insurance companies determine medical necessity. Medical necessity typically is required from Cigna, Aetna, UnitedHealthcare, Blue Shield of California, Anthem Blue Cross, and other health insurers. Finally, it covers the next steps after receiving an Enbrel health insurance denial. If you receive an Enbrel health insurance denial, contact the Law Offices of Scott Glovsky.
What Illnesses does Enbrel Treat?
Physicians prescribe Enbrel for autoimmune diseases including the following:
- Moderate to severe rheumatoid arthritis to improve overall function, to help lessen signs and symptoms, and to help stop joint damage from getting worse
- Psoriatic arthritis to help reduce joint damage and joint pain, to help get clearer skin, and to help improve physical function
- Moderate to severe plaque psoriasis to help reduce inflammation and relieve scaly, red skin
- Ankylosing spondylitis to help reduce inflammation and help relieve swelling, morning stiffness, and back pain, and
- Moderate to severe polyarticular juvenile idiopathic arthritis to help reduce inflammation that causes swelling, stiffness, and joint pain
See the FDA medication guide here.
What is Enbrel?
Enbrel is a pharmaceutical biologic medication given to individuals with specific autoimmune diseases. It is a tumor necrosis factor-alpha (TNF-alpha) blocker. TNF-alpha is a protein produced by the immune system that is critical for the body’s defense against infections and cancers. But in patients with certain autoimmune diseases, too much TNF-alpha can destroy healthy cells. Enbrel works to block TNF-alpha to help prevent inflammation and damage from the overproduction of the TNF-alpha protein.
How is Enbrel administered?
Enbrel is injected under the skin like insulin injections.
How often do you need to take Enbrel?
You take a 50 mg injection weekly.
Are there risks with Enbrel?
As a TNF-alpha blocker, Enbrel is an immunosuppressant drug so patients are more susceptible to infections. There is also an increased risk of certain cancers. You shouldn’t get a live vaccine while on Enbrel since the vaccine may not work as well.
How much does Enbrel cost?
Enbrel costs $1,389.24 per week, so a 4-week supply costs $5,556.96. Because of this high cost, most people use their health insurance to get Enbrel.
Is Enbrel given as a stand-alone drug?
Enbrel is used alone or together with methotrexate.
Depending on what condition Enbrel is prescribed for, doctors may start with other treatments before putting a patient on Enbrel. Why? Because Enbrel is an expensive drug and often doctors begin with less expensive treatments. In addition, sometimes health insurance companies deny Enbrel and suggest Step Therapy.
Are there alternative drugs to Enbrel?
Yes, sometimes practitioners start patients on treatments or alternate drugs that are less expensive. The selection depends on the health condition treated. Here is a list of some alternatives:
- Rheumatoid Arthritis: RA is sometimes hard to diagnose. Treatment goals include controlling inflammation, reducing disability, and helping to ease pain. Treatments include DMARDs, NSAIDs like ibuprofen and naproxen, steroids and biologics. Biologics include Orencia, Kineret, Remicade, Enbrel, Rituxan, and others.
- Psoriatic Arthritis: Oftentimes OTCs such as NSAIDs can reduce inflammation and help ease pain. Some of these include ibuprofen (i.e., Advil and Motrin IB)and naproxen sodium (Aleve). DMARDs slow the disease’s progression and help avoid lasting damage in some tissues and joints. Biologics here include Humira, Cimzia, Enbrel, Simponi, Stelara, and others.
- Plaque Psoriasis: Drugs and treatments aim to stop skin cells from growing quickly and to remove scales. These often include light therapy, creams, and injected or oral drugs. Topical therapy incorporates retinoids, calcineurin inhibitors, vitamin D analogues and corticosteroids, and more. Light therapy can be UVB, sunlight, and other types. Injections and oral medications include steroids, retinoids, methotrexate, Enbrel, Remicade, Humira, Stelara, and more.
- Ankylosing Spondylitis: Practitioners may treat this disease with NSAIDs like naproxen and ibuprofen. Unfortunately, these OTCs help with pain, stiffness and inflammation, but they may also lead to GI bleeding. TNF inhibitor biologics used include Humira, Enbrel, Remicade, Simponi and Cimzia. Sometimes IL-17 inhibitors like Cosentyx and Taltz are prescribed.
- Polyarticular Juvenile Idiopathic Arthritis: This form of arthritis impacts 5+ joints in the first 6 months of having JIA. JIA, formerly known as “Juvenile Rheumatoid Arthritis,” is the most common form of arthritis in kids under 16. This can lead to ongoing joint pain, stiffness and swelling. Some forms may cause growth issues, joint problems, and inflammation in the eye. As such, treatments try to reduce inflammation and pain, stop further damage, and help with general function. Like some of the conditions above, doctors use NSAIDs, DMARDS and Biologics. Biologic include TNF blockers like Enbrel, Humira, Remicade, and others. And steroids like prednisone help treat symptoms.
Will Insurance Companies Cover Enbrel?
Medicare (called, “Medi-Cal” in California) and Medicaid, both government insurers, may cover Enbrel because they generally cover pharmaceuticals approved by the FDA. Of course. coverage differs by state. Note that many Medicare Part D and Medicare Advantage Part C plans cover Enbrel. Medicare Part D programs include private health insurers to help cover pharmaceutical drug costs. These Part D programs have formularies with medications in tiers. Tier 1 is the lowest cost tier, and there may be 6 or more tiers. Enbrel is typically in Tier 5 or 6, meaning as a “specialty” biologic drug your copay costs may be high. Medicare Advantage Part C include private health insurers and often cover things not covered in straight Medicare. These plans differ based on where you live and the type of coverage you have. Finally, there is Medigap coverage that assists with deductible, copayment and coinsurance costs. Your specific Medigap plan may or may not assist with pharmaceutical drugs.
And keep in mind that all private health insurance companies are different. Companies like Cigna, Kaiser, UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Aetna and others have different internal policies. Their policies are based on how each one evaluates new drugs and a potential Enbrel health insurance denial.
What Role Do Pharmacy Benefit Managers (PBMs) Have in My Access to Medications?
Pharmacy Benefit Managers are third-party companies that manage medication benefits for health insurance companies, Medicare Part D plans, and some employers and pharmacies. They are middlemen in the pharmaceutical supply chain — they negotiate drug prices with pharmaceutical companies and pharmacies. PBMs have a major impact defining three things. These three include determining drug costs for insurers, member access to these medications, and how much pharmacies get paid.
PBMs are often criticized. Why? PBMs are affiliated with health insurance companies, their own pharmacies, healthcare entities, and physician’s offices. Some have even merged with health plans and chain pharmacies and established their own pharmacies. An example is CVS and Aetna. And very few PBMs control a huge percentage of plans. Only 3 PBMs control nearly 80% of drug benefits for 260 million Americans. Some feel this is a monopoly. Also, there is not a lot of government oversight of or transparency into PBM actions. An example is that PBMs negotiate discounts and rebates from drug companies, but often these savings aren’t passed along to members. Independent and some specialty pharmacies feel they are disadvantaged because their customers are at times forced to go to other pharmacies and they have low reimbursement rates. And some physicians feel they cannot prescribe the medication they want for their patients because the drug isn’t in the formulary.
How does this impact you? PBMs develop prescription formularies for insurance companies. And formularies impact which prescriptions you can take as well as your out-of-pocket costs. So PBMs have a large impact on you.
How Do Various Health Insurance Companies Evaluate Medication Claim Requests?
Each insurer established its own “medical” or “pharmacy” policies. These policies include internal rules defining which treatments and/or medications are “medically necessary.” (Medically necessary medications are included in “formularies.”) Of course, insurers track FDA approvals of new pharmaceuticals. Company pharmacists research medical information about the drugs. Then, they provide a suggestion on whether medications like Enbrel are medically necessary or experimental/investigational.
Typically, health insurance companies take their suggested policies to external doctors who help determine if the policies are suitable. Yet, there are oftentimes additional motivations at work. Insurers typically compensate the external doctors. Because of this, there could be an incentive to uphold an overly constrained policy. Also, sometimes the external doctors wish to work for the insurer. This adds an additional enticement to affirm the suggested policies. And corporate bottom lines impact medically necessary medication decisions.
Sadly, insurance company policies are frequently overly restrictive. The policies may not include what independent physician specialist associations determine is safe and effective for treating specific conditions. “Generally accepted standards of medical practice” refers to standards based on trustworthy scientific evidence that is published in peer-reviewed medical journals. These standards are generally recognized by the relevant medical experts and are accepted by other healthcare practitioners in the community. Regrettably, an insurer’s policy often differs from the patient’s doctor recommendations.
When is Enbrel Medically Necessary and when is it Experimental / Investigational?
If a pharmaceutical or treatment is not considered medically necessary, it is typically believed to be “experimental or investigational.” Drugs approved by the FDA can be considered experimental or investigational by the insurance company policy. And sadly, almost any drug or treatment can be considered experimental or investigational. Why is this the case? It is due to how insurers define investigational. A good example is when a drug helps some people but not everyone. And we know that almost every drug on the market can help some but not everyone. Even aspirin doesn’t work for everyone.
You Received an Enbrel Health Insurance Denial. Now What?
What you do depends on your type of health plan. Of course, you have the option to appeal an Enbrel denial. How you submit your denial depends on if you have an ERISA or non-ERISA plan. You may not know what type of plan you have. If this is the case, you can speak with your plan administrator.
In many cases when an employer provides health insurance, the plan is an ERISA plan. Exceptions include the following: government employee plans, religious institution employee plans, individual and family plans bought from Covered California, small business plans that only involve the owners, and a majority of plans bought from private insurers. These insurance companies include Kaiser Permanente, Blue Shield of California, Aetna, HealthNet, UnitedHealthcare, Anthem Blue Cross, and others.
If you have an ERISA plan, you should file an appeal. But ideally, speak with an ERISA attorney before you do. Read more about ERISA plans and options here. If you have a non-ERISA plan, you have many options. First look at the reason for the denial. Go here to learn more.
Contact Law Offices of Scott Glovsky if You Receive an Enbrel Health Insurance Denial
The Law Offices of Scott Glovsky has been representing injured consumers and health insurance denial victims for 22 years. We focus on health insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related litigation. We get justice for our clients and hold the wrongdoers accountable.